NCC222314_FRO Submitted_20220628

3201 -180 7--,
FINANCIAL. RESPONSIBILITYIOWNERSHIP 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 Environment and Natural Resources. (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.)
Project Name: Hanqar Taxilane, Access Road and Parking, and Utilities
2. Location of land -disturbing activity: County Moore County City or Township Carthage
Highway/Street 7825 Aviation Drive Latitude 35°14'04.65"N Longitude 79023'49.95"W
Approximate date land -disturbing activity will commence: July 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Airport
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9
6. Amount of fee enclosed: $ 585.00 . 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). .
7. Has an erosion and sediment control plan been filed? Yes No Enclosed: X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ronald Maness E-mail Address rmaness a(�,moorecountyairport.com
Telephone [phone] Cell # 910-638-3217 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Moore County Airport Authority 910-692-3212 910-692-8216
Name Telephone Fax Number
P.O. Drawer 5809 7825 Aviation Drive
Current Mailing Address Current Street Address
Pinehurst NC 28374 Carthage NC 28327
City State Zip City State Zip
10. Deed Book No.240,318,319,397,433 Page No.655,122,612,432,682 Provide a copy of the most current
deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Moore County Airport Authority rmaness(aD-moorecountyairport.com
Name E-mail Address
P.O. Drawer 5809 7825 Aviation Drive
Current Mailing Address Current Street Address
Pinehurst NC 28374 Carthage NC 28327
City State Zip City State Zip

Telephone [phone] Fax Number 910-692-8216
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
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number.
State Zip
(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
Current Mailing Address
City
Telephone,
E-mail Address
Current Street Address
State Zip City State Zip
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.
Ronald Maness
e or print named 1
Signature
State of North Carolina, hereby certify that _
personally before me this day and being
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Airport Manager
Title or Authority
I
Date
a Notary Public of the County of Vec�
appeared
duly sworn acknowledged that the above form was
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