NCC222464_FRO Submitted_20220712

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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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: BATTLEGROUND STORAGE
2. Location of land -disturbing activity: 4094 BATTLEGROUND AVENUE
3. Approximate date land disturbing activity will be commenced: JAN 2022
4. Development type: Commercial X Industrial_ InstitutionalT MF residential
5. Approximate acreage of land to be disturbed: 4.35
6. Has an erosion and sediment control plan been filed? Yes X No
7. Landowner(s) of Record (attach pages to list additional owners):
LEOTERRA BATTLEGROUND LLC 336-671-1858
Name
110 A SHIELDS PARK DR
Current Mailing Address
KERNERSVILLE NC 27284
City State Zip
8. Deed County: GUILFORD
1 CIGPl lul IC
SF residential
[e-mail]
Email
110 A SHIELDS PARK DR
Current Physical Street Address
KERNERSVILLE NC 27284
City State Zip
Book: 8452 Page: 1165
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: BUDDY LYONS Telephone: [phone]
E-mail: buddy@leoterradevelopmentcom
Part B:
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 firm is a sole proprietorship the name of the owner
or manager may be listed as the financially responsible party.
LEOTERRA BATTLEGROUND LLC 336-671-1858 [e-mail]
Name
110 A SHIELDS PARK DR
Current Mailing Address
KERNERSVILLE NC 27284
City State Zip
Telephone Email
same
Current Physical Street Address
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
Telephone Email
Current Mailing Address
Current Physical Street Address
City State Zip
City 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. -
BUDDY LYONS
336-671-1858 buddy@leaterradevelopment_com
Name
Telephone Email
110 A SHIELDS PARK DR
110 A SHIELDS PARK DR
Current Mailing Address
Current Physical Street Address
KERNERSVILLE NC 27284
KERNERSVILLE NC 27284
City State Zip
City State Zip
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.
n/�
BUDDY LYONS
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Title or Aut rity
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Date
I, Ro4& BLAA k-ar a Notary Public of the County of McA)en6u!S3
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State of Nord Garo),Ac, hereby certify that 6t_r Sid' Ap ` WA h nS
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 Ovvem, 20 0L)
My Commission expires
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