NCC230635_FRO Submitted_20230317

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
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. Mount Ai Airport - Parallel TaxiA Extension
1. Project Name p araTaxiway
2.
3.
Location of land -disturbing activity: CountySurry
Highway/Street Howard Woltz Jr. Way Latitude 36.45466
City or Township Mount Airy
_ Longitude 80.5531
Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Airport Development
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.0
6. Amount of fee enclosed: $ 1,200.00 . 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 Parrish and Partners of North Carolina E-mail Address [e-mail]
Telephone [phone] cell # 336.858.0614 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mount Airy Surry County Airport ATTN: Airport Manager 336.386.3700
Name
Telephone Fax Number
146 Howard Woltz Jr. Way
146 Howard Woltz Jr. Way
Current Mailing Address
Current Street Address
Mount Airy, NC 27030-9020
Mount Airy, NC 27030-9020
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) 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.
Mount Airy - Surry County Airport Authority
[e-mail]
Name
E-mail Address
118 Hamby Road
118 Hamby Road
Current Mailing Address
Current Street Address
Dobson, NC 27017
Dobson, NC 27017
City State Zip
City State Zip
Telephone [phone]
Fax Number 336.401.8216

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
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:
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.
George Crater Airport Manager
Type or print name / Title or Authority
3 Za a �
Sjgnatur Date
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1
I, �:� , a Notary Public of the County of
State of North Carolina, hereby certify that r ? appeared
personally before me this day and being duly sworA acknowledged that the above form was
executed by
Witness po% nd-grid notaI, this _day of , 20
i A
' r Notary
My commission expires
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