NCC216611_FRO Submitted_20211207

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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
Project Name
Contract 2015-003, Downtown Greenway Phase 4 and ANY Greenway
2. Location of land -disturbing activity: County Guilford City or Township Greensboro
Highway/Street W• Friendly Ave. Latitude 36.0730 N
Longitude
3. Approximate date land -disturbing activity will commence: January 2022
79.7995 W
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.0 Acres
6. Amount of fee enclosed: $ $910.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed Yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Melinda King
E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Greensboro
Name
P.O. Box 3136
Current Mailing Address
[phone] [phone]
Telephone Fax Number
300 West Washington Street
Current Street Address
Greensboro NC 27402-3136 Greensboro NC 27402-3136
City State Zip City State Zip
10. Deed Book No. Page No.
Part B.
Provide a copy of the most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
City of Greensboro
Name
P.O. Box 3136
Current Mailing Address
Greensboro NC 27402-3136
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
300 West Washington Street
Current Street Address
Greensboro NC 27402-3136
City State Zip
Fax Number [phone]

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:
NIA
Name
Current Mailing Address
City
Telephone
State
0
E-mail Address
Current Street Address
City State Zip
Fax Number
(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:
NIA
Name of Registered Agent
Current Mailing Address
City
Telephone
State
Zip
E-mail Address
Current Street Address
City State Zip
Fax Number
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 � there by any change in the information provided herein.
F, Oar, 1, � VM(4 r
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Chief Design Engineer
Title or Authority
Date
I, I Iisk_OL + -ac , a Notary Public of the County of , l
State of North Carolina, hereby certify that --FA n rs r appeared
personally before me this day and being duty sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this AanNay of f , 2g 21
Wiilisha R Smith Branch icto [:�f
Notary public Notary
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