NCC243587_FRO Submitted_20241120

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: Interstate Industrial Park at 201 East JJ Drive
2. Location of land-disturbing activity: Northeast intersection of JJ Drive&Firestone Drive
3. Approximate date land disturbing activity will be commenced: 12-01-2022
4. Development type: Commercial Industrial ✓ Institutional MF residential SF residential
5. Approximate acreage of land to be disturbed: 4.57 acres
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 336-292-9161 [e-mail]
Name Telephone Email
2275 Vanstory Street Suite 200 2275 Vanstory Street Suite 200
Current Mailing Address Current Physical Street Address
Greensboro NC 27403 Greensboro NC 27403
City State Zip City State Zip
8. Deed County: Guilford Book: 3389 Page: 208
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Brian Hecke 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.
KOURY CORPORATION 336-292-9161 [e-mail]
Name Telephone Email
2275 Vanstory Street Suite 200 2275 Vanstory Street Suite 200
Current Mailing Address Current Physical Street Address
Greensboro NC 27403 Greensboro NC 27403
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 nam Title or Authority
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Signature Date
I,N>?y 1.-4vin Na , a Notary Public of the County of GLAI IV-C1
State of N.1,ov �1 vO{C v u , hereby certify thatTV1G,v1 *Heeke
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 lay of UP_►M, , •
My Commission expires Zt ZDZ-LP t voAd.
CHERYL LYNN GRAY
NOTARY PUBLIC
Guilford County
North Carolina
My Commission Expires May 2,2026