NCC230646_FRO Submitted_20230310

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 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. AIR TRAFFIC CONTROL TOWER PROJECT
1. Project Name
2. Location of land -disturbing activity: CountyHenderson CityorTownship Mills River
Highway/Street 146 Westfeldt Rd Latitude 35 25' 54.71 N Longitude 82 32' 34.07 W
3. Approximate date land -disturbing activity will commence: NOVEMBER 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Airport
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.12
6. Amount of fee enclosed: $ 1,700 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 James Moose, P.E E-mail [e-mail]
Telephone [phone] cell # 704-650-6050 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Greater Asheville Regional Airport Authority 828-684-2226 828-684-3404
Name Telephone Fax Number
61 Terminal Drive, Suite 1
Current Mailing Address Current Street Address
Fletcher NC 28732
City State Zip City State Zip
10. Deed Book No. 1584 Page No. 350 Provide a copy of the most current deed.
Part B.
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.
Greater Asheville Regional Airport Authority [e-mail]
Name E-mail Address
61 Terminal Drive, Suite 1 same
Current Mailing Address Current Street Address
Fletcher NC 28732
city
State Zip City
State
Telephone [phone] Fax Number828-684-3404
0

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:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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.
Lew Bleiweis President and CEO
Typeorprint name
Z
Signature
Title or Authority
9 T_ z v z-2
Date
Mi ekiVj),I� a Notary Public of the County of He.F'C&fimo
State of North Carolina, hereby certify that _ �_2 \,j ?S t W C,,s appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this . t �, day of j P p4j,-.,kU , 20 �p
. l " yuk
ELLEN HSJOY ��� Notary ]
HENDERSON COUNTY,4 My commission expires
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