NCC223431_FRO Submitted_20221004

NC Department of
Environmental Quality
Received
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JUL 0 1 2022
SEDIMENTATION POLLUTION CONTROL ACT
W'nstont Sa em
No person may initiate any land -disturbing activity on one or more acres as covered by the Act be ore his orm
and an acceptable erosion and sedimentation control plan have been completed and apprBV0q"h9L1fA
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project NameCrossfield Taxiway — Package 2 Grading
2. Location of land -disturbing activity: County Guilford City or Township Greensboro
1000A Ted Johnson Parkway
Highway/Street Latltude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land -disturbing activity will commence:AUgust 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):AVlattion
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 258
6. Amount of fee enclosed: $25,800 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameLorin Akins E-mail [e-mail]
Phone: Office # 336.665.5600 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Piedmont Triad Airport Authority 336.665.5600 336,907.0540
Name Phone: Office # Mobile #
1000A Ted Johnson Parkway 1000A Ted Johnson Parkway
Current Mailing Address Current Street Address
Greensboro NC 27409 Greensboro NC 27409
City
State Zip City
State
Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Piedmont Triad Airport Authority [e-mail]
Company Name E-mail Address
1000A Ted Johnson Parkway 1000A Ted Johnson Parkway
Current Mailing Address Current Street Address
Greensboro NC 27409 Greensboro NC 27409
City State Zip City State Zip
Phone: Office # 336.665.5600 Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Type or print name
a4; -
Signature
Dep,- , 0� CcnsFruclk,U✓1
Title or Authority
(,- 3 0 - 2Z
Date
a Notary Public of the County of
State of North Carolina, hereby certify that ► rjS appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this da o"O{, 202z
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•�`��. t�, Notary
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f- WY
(j) COMMISSION EXPIRES
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record. -
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 9 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
City
Phone: Office #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
State Zip City State
Mobile #
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
E-mail Address
Zip
State Zip
State Zip
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #