NCC221480_FRO Submitted_20220504

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 and within the
corporate limits or the extraterritorial jurisdiction of the City of Burlington before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Burlington's
Erosion Control Administrator. (Please type or print, if the question is not applicable or the e-mail and/or fax
information unavailable, place N/A in the space provided. Blank spaces and/or inaccurate information will be
considered incomplete and could result in a disapproved plan.)
Part A.
1. Project Name Greeson Lane
2. Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street Huffman -Mill Road Latitude 36.0452 Longitude-79.5180
3. Approximate date land -disturbing activity will commence: 5/1/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 63.0 acres
6. Amount of fee enclosed: $ 3,885.00 . The application fee of $225 for the initial 2 acres
plus $60 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-
acre application fee is $645).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed Yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Clay Mize E-mail Address [e-mail]
Telephone Cell # 336-971-3574 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Greeson Glenn Ray & Greeson Gary Dean
Name Telephone Fax Number
110 29th Avenue Drive NW, Apt. 007 3843 Greeson Lane
Current Mailing Address Current Street Address
Hickory NC 28601 Boone Station Township NC 27215
City State
10. Deed Book No. 3574
11. Tax Map No. 3-23-27
12. Parcel ID 106051
Zip City State Zip
Page No. 0874 Provide a copy of the most current deed.
Block Lot No.
GPIN (State ID) 8843660578
Part B.
1. Person(s) or firm(s) who is financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
LeoTerra Development, Inc. [e-mail]
Name E-mail Address
110-A Shields Park Drive 110-A Shields Park Drive
Current Mailing Address Current Street Address
Kernersville NC 27284 Kernersville NC 27284
City State Zip City State Zip
Telephone [phone] Fax Number n/a

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone,
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 should there be any change in the information provided herein.
GI4r1S�O 1wi Cons Gres► }
or PFM name Title or Authority
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an aeure Date
I, R0 + kYe, .�.,nLer a Notary Public of the County of MC 6bvrl4
State of North Carolina, hereby certify that 6kr►54 '.'- r! onS appeared
personally before me this day and being duly sworn acknow edged that the above form was
executed by him.
Witness my hand and notarial seal, this IY� day of MOJC,, , 20 as
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