NCC243058_FRO Submitted_20241002

GREENSBORO
NORTH CAROLINA
Erosion and Sediment Control Plan Submittal
In this packet,you will find plan submittal instructions, a copy of the grading permit application and
financial responsibility forms, and a checklist with plan requirements for your reference.
Required documents for initial review:
• Grading permit application and financial responsibility forms
• Plan
• Calculations
Plan submittal format:
Please submit all plans and documents as PDF files. The complete plan should be included as
multiple pages in one PDF file. Additional files can also be uploaded as needed (i.e.: grading
permit application, calculations, etc.).
How to submit a plan:
Plans and associated documentation should be uploaded through the City's Plan Review and
Tracking System: www.greensboro-nc.gov/PlanReviewAndTracking
Additional Information:
After plans are reviewed and ready for approval,you will need to submit 3 sealed hard copies of
the approved version of the plan and associated paperwork including the original notarized copy
of the grading permit application and financial responsibility/ownership forms. Sites with a
proposed land disturbance of five or more acres also require a surety of$2000 per disturbed
acre. Technical Review Committee or Grading Only plan approval is also required prior to
issuance of the grading permit.
Submittal address:
City of Greensboro
Water Resources Department, Erosion and Sediment Control Section
2602 South Elm-Eugene St.
Greensboro, NC 27406
•
Contact Information:
If you have any questions regarding this process, please contact Cass Heaton at
cass.heatonPgreensboro-nc.gov or(336)373-2030
Rev.9-2021
PO BOX 3136 • GREENSBORO NC 27402-3136 • WWW.GREENSBORO NC.GOV • 336-373-CITY (2489)
64Q

City of Greensboro, NC
Grading Permit Application
GREENSBORO
NORTH C?901IN•
Owner Information: Permit#:
Company 101 Chimney Rock LLC Contact Brian Hall
Address 309 Gallimore Dairy Road Suite 102 Phone No. 336-544-2600
Greensboro,NC 27409 Email [e-mail]
Project Information:
Project Name Burnt Poplar Road Laydown Yard
Address 6220 Burnt Poplar Road Latitude 36.071780 Longitude •79.918279
Greensboro,North Carolina Tax Map 7824866886
Area Graded 4.71 Acres and/or 205.104 sq.ft. Site Area 6.05 Acres and/or 263,482 sq.ft.
Proposed Use of Property grade,fence,landscape as required,and stone pave for future use Zoning HI.Heavy Industrial
Brief Description of Project Location It is located next to the Buckeye Terminals Greensboro I petroleum plant.
The site is a moderately wooded area that includes a split of soils between majority coronaca clay loam soils and minority Mecklenburg•Urban land complex soils.
Brief Description of Development Plan Samet Corporation intends to grade,fence,landscape as required,and stone pave the property for future use.
If this application is approved by the properly designated authorities and a grading permit issued,the undersigned does hereby agree to
comply with all applicable City regulations under the Greensboro Soil Erosion and Sedimentation Control Ordinance as described in
Chapter 30-12-6 of the Greensboro Land Development Ordinance.
Before beginning any grading operation, call f on- ite pr c struction meeting, and when area has been protected, call for final
inspection. ,
Signature of owner,developer,or agent: Date: I tie 1
FOR OFFICE USE
Approved by Date
Permit No. Date
Tracking No. Date Approved Tracking Type: TRC Grading
Surety Amount Surety Type: LOC SCB HOD Check
Surety Number Surety Expiration Date
Temporary Measures Approved Date
Final Inspection Approved Date

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CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
4ff�# 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: Burnt Poplar Road Laydown Yard
2. Location of land-disturbing activity: Burnt Poplar Road,Greensboro, North Carolina(36.071780, -79.918279)
3. Approximate date land disturbing activity will be commenced: 3/18/2024(As soon as all permits are in hand)
4. Development type: Commercial Industrial i Institutional_MF residential SF residential
5. Approximate acreage of land to be disturbed: 4.71
6. Has an erosion and sediment control plan been filed? Yes No
7. Landowner(s)of Record (attach pages to list additional owners):
101 CHIMNEY ROCK LLC 336-544-2600 [e-mail]
Name Telephone Email
5942 Tarleton Dr 5942 Tarleton Dr
Current Mailing Address Current Physical Street Address
Oak Ridge NC 27310 Oak Ridge NC 27310
City State Zip City State Zip
8. Deed County: Guilford County Book: 8754 Page: 3069
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: David A.Ross Telephone: [phone]
E-mail: [e-mail] 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.
101 Chimney Rock LLC 336-544-2600 [e-mail]
Name Telephone Email
309 Gallimore Dairy Rd,Suite 102 309 Gallimore Dairy Rd,Suite 102
Current Mailing Address Current Physical Street Address
Greensboro NC 27409 Greensboro NC 27409
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:
101 Chimney Rock LLC 336-544-2600 [e-mail]
Name Telephone Email
309 Gallimore Dairy Rd,Suite 102 309 Gallimore Dairy Rd, Suite 102
Current Mailing Address Current Physical Street Address
Greensboro NC 27409 Greensboro NC 27409
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 o • int ame r' Title or Auth ity
2.4
Signet ' Date ( 1I
I, L. Ai 4 C ck(a Notary Public of the County of `P—Ari -11)o(-PA
State of N L 76,4-u L—t r1 , hereby certify that 5 te--( tom-) A-L--
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 19 day of JA-MA --(1, 20 d-`f .
My Commission expires L— 3 , Zo 2-1 •
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NOTARY
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