NCC231022_FRO Submitted_20230414

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 N/A in the blank).
Part A:
1. Project Name: Greensboro Terminal Ethanol Rail Offload and Associated Terminal Pipeline
2. Location of land-disturbing activity: multiple parcels near 6907 W.Market Street,Greensboro, NC
3. Approximate date land disturbing activity will be commenced: April 2023
4. Development type: Commercial Industrial ✓ Institutional MF residential SF residential
5. Approximate acreage of land to be disturbed: 13.7
6. Has an erosion and sediment control plan been filed? Yes ✓ No
7. Landowner(s) of Record (attach pages to list additional owners):
See attached list
Name Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
8. Deed County: See attached list Book: See attached Page: See attached
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Demond Cusinginberry Telephone: [phone]
E-mail: [e-mail] Other: NIA
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.
Kinder Morgan Southeast Terminals, LLC 713-369-8456 [e-mail]
Name Telephone Email
1001 Louisiana Street,Suite 1000 1001 Louisiana Street,Suite 1000
Current Mailing Address Current Physical Street Address
Houston TX 77002 Houston TX 77002
City State Zip 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:
Jim Anderson 252.342-5033 [e-mail]
Name Telephone Email
214 Cedar Street 25 Westie Way
Current Mailing Address Current Physical Street Address
Emerald Isle NC 28594 Ferdericksburg VA 22406
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:
Jim Anderson 252-242.5033 [e-mail]
Name Telephone Email
214 Cedar Street 25 Westie Way
Current Mailing Address Current Physical Street Address
Emerald Isle NC 28594 Fredericksburg VA 22406
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.
Michael Pitta Vice President
Type or print name Title or Authority
/.- / /
Signature Date
I, ° A 14— , a Notary Public of the County of -k
CFI
State of -- E4 ,6 , hereby certify that \ r _.�
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 `i I , 20 4.
My Commission expires If:, w .
f '`�'s't�x.: KARIAS.FIKAC
.� j. My Notary ID#125063241 I
' Expires October 21,2024