NCC221176_FRO Submitted_20220328

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
forrr, and an aoceplable erosion and sedimentation control plan have been completed and appraved by
the Land Quality Section N.0 Deoartment of Environmental Ouali:y. SLIOM11 the completed form to the
appropriate Regional office- (Please type or print and. if the question is not applicable or the e-mail ard►
or fax information unavailable, place N!A in the blank.)
Part A. Airfield Pavement Rehabilitation
1, Project Name
7
8
;,
Location of land -disturbing activity County Davidson City ar Township Lexington
HighwaylStreet 1673 Aviation WRY LatnudeN35046'51 LongitudeW80-18114"
Approximate dale land -disturbing activity will commence July 2022
Purpose of development Iresident�iai. commercial, industnat. institutional etc.i Transportation
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 23.4
Amount of fee enclosed 5 2,400 The application fee of $100.00 per acre
{rounded up to the next acre} is assessed wit nout a ceiling amount (Example 8 10 ac = $900-00)
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to _ontact snould erosion and sediment, control issues arise dur ng land -disturbing act+wly
Name Rick Phillips Email Address rphillipsasun-wd.eom
Telephone NIA Cell # 336-382-8807 Fax # N/A
Landowrer�s) of Record lattach accompanied cage to list additional owners)
Davidson County Airport Authority 336-956-7774
Name
1673 Aviation Way
Current Madirg .Andress
Lexington NC
City State
TO Deed Book No. 0944
Telephone
1673 Aviation Way
Current Street Andress
27292 Lexington NC
Zip City
Page No 0981
State
NIA
Fax Number
27292
Zip
Provpde a copy of the most current deed
Part B.
1 Companyl.ies) or firm(s) who are financial?y responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet) tI the company or f►►n is a sole prvprietursho
the name of the o:mer ❑► rnanaper army be wed as the rinanoiUy resporis►We pally.
Davidson County Airport Authority NIA
Name
1673 Aviation Way
Current Mailing Address
Lexington NC
Ctty State
Telephone 336-382-a307
E-mail Address
1673 Aviation Way
Current Street Address
27292 Lexington NC 27292
Zip City
Fax Number N/A
Sale
Z10

2. (a) If the Financially Responsible Party is rat a resident of North Carolina give name and street address
of the des grated North Carolina Agent
NIA
Nar•e E-mail Address
Current Marling Address Current Slree: Address
C ty State Z p City Sate Zip
Telephone F a i Numf;e,
(b) If the Financially Responsible Party is a Partnership or other person engaging in business ender an
assumed name. attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporatior g ve narne ana street address of the Registered Agent
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fay Nur^be,
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-;n-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 prov,ded herein
Rick Phillips
Chairman - Airport Authority
Type of print name Title or Author ty
• 2 to- /Z-02-4.
Sign t Date
a Notary Public of the County of
State of North Carolina, hereby certify thatappeared
personally before me this day and bung duly swo n ackhovAedged that the above form was
executed by him
► fitness my hand and notan4S"jthis A ._ day of i �lGi i'.20
.•'"�
Seal d' i°U1300 ?-
Notary
My comrr..issior expires. �'}�G� )