NCC220750_FRO Submitted_20220215

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place NIA in the blank).
Part A:
1. Project Name: i I lo,)
2. Location of land -disturbing activity, CLL e Rd. i C,46a 14C
3. Approximate date land disturbing activity will be commenced: _ 1_1 2 1
4. Development p type: Commercial Industrial Institutional MF residential S!' residential _T
5. Approximate acreage of land to be disturbed: 149,741
6. Has an erosion and sediment control plan been filed? Yes V� No
7. Landowner(s) of Record (attach pages to list additional owners):
Name
141425 1oAum ]&&L , 3"ite Lo t
Current Mailing Address
6irtw4,sra NG 0
City State ��!
Zip
8. Deed County: 14iIor d
336-251-9010 _bSrhaI i,AZau[,ro l
Telephone Emaij '
14LIZ� cc 'Euitc, [at
Current Physical Street Address
City State Zip
Book: T1 _ Page: ! 3 S93 *3 5
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: fkrN 5. S ie cl, t
E-mail: 6 S r_61d`ejg @ tit , Cow_
Part B:
Telephone: w 2.ijla
Other.
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 Arm is a sole proprietorship the name of the owner
or manager may be listed as the financially responsible party.
D•llor� plc r_ LL.0
Name
._'4q 5 M K me,*- Ce Sri lot
Current Mailing Address _
C1�' f'Pdr3��aPd � C �7�09
City State zip
53C -Z Z g 010 5r 1 c')tZvl •Cod,
Telephone Email
14,425 M40LU
Current Physical Street Address
rerdt360(6 N C 21go?
City State Zip

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
Current Mailing Address
City State Zip
Telephone Email
Current Physical Street Address
City State
9T
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed
name, attach a copy of the Certiflicate of Assumed Name. If the Financially Responsible Party is a Corporation,
give name and street address of the Registered Agent:
Name Telephone Email
Current Malting Address
City State
Zip
Current physical Street Address
City State Zip
The above information is true and correct to the beat 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.
ltil e oa
r
Typ. rPw�► Title or Authority
Signature Date
a Notary Public of the County of t�-
State of 11660 0 /7 .0-- _,hereby certify that
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s).
Witness my hand and notarial seal, this } day of c u , 20 .
My Commission expiresa�
Lynn Freeman
Notary Public
State Of North CaroNna
Guilford County
My Commission Expires
B12i 021