NCC240001_FRO Submitted_20240110

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 address or phone
number is unavailable, place N/A in the blank )
Part A.
1. Project Name Rockingham County Shiloh Airport Excess Soil Sites
2 Location of land-disturbing activity County Rockingham City or Township Shiloh
Highway/StreetSettle Bridge Rd Latitude(deumaidegrees) Longitude(de_me degrees
3 Approximate date land-disturbing activity will commence End of November 2023
4 Purpose of development(residential, commercial industrial, institutional, etc) industrial
14513
5 Total acreage disturbed or uncovered(including off-site borrow and waste areas)
6 Amount of fee enclosed $ 1 ,400 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 p No ❑
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name James Daniel Lynch E-mail Address dlynch©jrlynchandsons.com
Phone office# [phone] Mobile# [phone]
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Gregory Manuel [phone]
Name Phone Office# Mobile#
3241 Settle Bridge RD 3241 Settle Bridge RD
Current Mailing Address Current Street Address
Stoneville, NC 27048 Stoneville, NC 27048
City State Zip City State Zip
1541
10 Deed Book No Page No 128 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)
Jimmy R. Lynch & Sons, Inc. [e-mail]'
Company Name E-mail Address
P. O. Drawer BB 314 S Academy St.
Current Mailing Address Current Street Address
Pilot Mountain, NC 27041 Pilot Mountain, NC 27041
City State Zip City State Zip
Phone: Office# [phone] 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:
James Daniel Lynch [e-mail]'
Name of Registered Agent E-mail Address
P. O. Drawer BB 14 S Academy St.
Current Mailing Address Current Street Address
Pilot Mountain, NC 27041 Pilot Mountain, NC 27041
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
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.
James Daniel Lynch President
Type or pri na e Title or Authority
\— \ —a3
Signatur Date
, a Notary Public of the County of Sdkro.
State of North Carolina, hereby certify that a,,rrie4 ,,:.44_\ L NCll appeared personally
before me this day and being duly sworn acknowledged that the above�rrm was executed by him/her
Witness my hand and notarial seal, this 1S day of N(>44.+y_b4/ , 20 c3
CL.44,q ..5"-vNvcx),Th
Notary
Cathy My commission expires ick \1 J Snow
Nott ry PVb?ro
Stale of North Carolina
County of Su+ry
t My Co ,m 1~,xpl:a6:
,`► ►, • +—

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:
Adam Richardson (336_) 340-2732
Name Phone: Office# Mobile#
130 Woodbriar Dr 130 Woodbriar Dr
Current Mailing Address Current Street Address
Stoneville, NC 27048 Stoneville, NC 27048
City State Zip City State Zip
Deed Book No. 1605 Page No. 1267 Provide a copy of the most current deed.
Landowner 3 of Record
John Webster [phone]
Name Phone: Office# Mobile#
1379 Whetstone Creek RD. 1379 Whetstone Creek RD.
Current Mailing Address Current Street Address
Stoneville, NC 27048 Stoneville, NC 27048
City State Zip City State Zip
Deed Book No. 831 Page No. 1423 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 B of the Financial Responsibility/Ownership Fonn for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone. Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone. Office# Mobile#