NCC243293_FRO Submitted_20241025

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any[and-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: Jefferson Glen Townhomes(#2024-1892)
2. Location of land-disturbing activity: 1816 New Garden Road
3. Approximate date land disturbing activity will be commenced: Summer 2024
4. Development type: Commercial Industrial Institutional MF residential ✓ SF residential
5. Approximate acreage of land to be disturbed: 4.4 Acs.
6. Has an erosion and sediment control plan been filed? Yes ✓ No
7. Landowner(s)of Record (attach pages to list additional owners):
SIMAAN NEW GARDEN,LLC 336.339.5023 [e-mail]
Name Telephone Email
6203 Wescott Drive _ 6203 Wescott Drive
Current Mailing Address Current Physical Street Address
Greensboro NC 27358 Greensboro NC 27358
City State Zip City State Zip
8. Deed County: Guilford Book: 8789,8809 Page: 1593,1262
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Jim Galyon Telephone: [phone],x13
E-mail: jgalyon@collinsga[yon.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.
SIMAAN NEW GARDEN,LLC 336-339-5023 [e-mail]
Name Telephone Email
6203 Wescott Drive 6203 Wescott Drive
Current Mailing Address Current Physical Street Address
Summerfield NC 27358 Summerfield NC 27358
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.
Ted Simaan Manager
Type or print nam Title or Authority
Signa Date
I, M‘C.1.4.1ke.— AIa r 1{-414 t , a Notary Public of the County of G t f ineat
State of 14.G . , hereby certify that TC
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 11 day of -5 ► M t , 20 2.`-t
My Commission expires t () , }=G�yv, Yy 2 O Z ct
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