NCC217007_FRO Submitted_20211217

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Davidson County Airport Corporate Hangar & Taxilane Expansion
1. Project Name
2. Location of land -disturbing activity: County,
Davidson I nVin ton
City or Township g
Highway/Street Aviation Way Latitude
Longitude.
3. Approximate date land -disturbing activity will commence: March 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):, Hangar Additions
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.5 acres
.1.
6. Amount of fee enclosed: $ 390.00 The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
35.7781
Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Karel Van Der Linden E-mail Address [e-mail]
Telephone [phone] Cell # 404-867-5535
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Davidson County Airport Authority 336-956-7774 336-956-7647
Name Telephone Fax -Number
PO Box 1067 1673 Aviation Way
Current Mailing Address Current Street Address
Lexington NC 27292 Lexington NC 27292
City State Zip city State Zip
10. Deed Book No. 944 Page No. 981 Provide a copy of the most current deed.
Part B.
1 Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Davidson County Airport Authority [e-mail]
Name
PO Box 1067
Current Mailing Address
Lexington NC
city
State
E-mail Address
1673 Aviation Way
Current Street Address
27292 Lexington NC 27292
Zip
City State Zip
Telephone [phone] Fax Number 336-956-7647

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible, Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone,
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
John Gray Board Chairman
Type or print name
Signature
Title or Authority
Date
1, 0:;S" a Notary Public of the County of Om�
State of North Carolina, hereby certify that z � S= appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of 20
Ryan
Sell V. CNOW Notar`��
NOTARY PUBLIC
,r,
dson County, North Carolina
t I
My Commission Expires: August 5,2025 My commission expires