NCC240249_FRO Submitted_20240129

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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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: FOUR SEASONS STATION SUBDIVISION PLAN AND CHIPOTLE SITE PLAN
2. Location of land-disturbing activity: 3227 W GATE CITY BLVD
3. Approximate date land disturbing activity will be commenced: AUGUST 1,2023
4. Development type: Commercial V Industrial Institutional MF residential SF residential
5. Approximate acreage of land to be disturbed: 5.17
6. Has an erosion and sediment control plan been filed? Yes ✓ No
7. Landowner(s) of Record (attach pages to list additional owners):
KOURY CORPORATION 336-292-9200 bcheek@koury corp.com
Name Telephone Email
2275 VANSTORY STREET 2275 VANSTORY STREET
Current Mailing Address Current Physical Street Address
GREENSBORO NC 27407 GREENSBORO NC 27407
City State Zip City State Zip
8. Deed County: GUILFORD Book: 3420 Page: 933
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: BRIAN CHEEK Telephone: [phone]
E-mail: bcheek@koury corp.com Other:
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.
KOURY CORPORATION 336-292-9200 bcheek@koury corp.com
Name Telephone Email
2275 VANSTORY STREET 2275 VANSTORY STREET
Current Mailing Address Current Physical Street Address
GREENSBORO NC 27407 GREENSBORO NC 27407
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:
Name Telephone Email
Current Mailing Address Current Physical Street Address
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:
Name Telephone Email
Current Mailing Address Current Physical Street Address
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.
Type or print name Title or Authority
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Signature Date
CL
I, JI 1�- a Notary Public of the County of I nd
•
State of NoY\'VI etul)IhflCk_ , hereby certify that yi�� 'W116—
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 jilt_ , 20
My Commission expires I o`!A i ;ADS
Constance Brinkley
NOTARY PUBLIC
Guilford County
North Carolina
My Commission Expires October 12,2025.