NCC222561_FRO Submitted_20220725

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:
Project Name: Guilford College Road Industrial Warehouse
2. Location of land -disturbing activity: 100 Guilford College Road, Greensboro, NC 27409
3. Approximate date land disturbing activity will be commenced: 6/1/2022
4. Development type: Commercial_ Industrial ✓ Institutional_ MF residential_ SF residential
5. Approximate acreage of land to be disturbed: 21.43
6. Has an erosion and sediment control plan been filed? Yes ✓ No,
7. Landowner(s) of Record (attach pages to list additional owners):
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Name Telephone ail
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Current Mailing Address Current Physical Street Address
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City State Zip City State Zip
8. Deed County: Guilford
Book: SEE RIGHT Page: SEE RIGHT
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: (� P"AJA Telephone: 0Q.3(0
E-mail: g010 g C9QUSQWet0 fne { •GOrv. Other:
Part B:
DB PG
65541885
65541885
37931646
3009 508
2953 228
1668 200
3189 280
38201194
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.
11 W\
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Name LTelephone mail
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Current Mailing Address Current Physical Street Address
U SQQPedt PA ROTS Sot�
City State Zip City State Zip

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent:
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Name Telephone Email
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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
Current Mailing Address
City State
Telephone Email
Current Physical Street Address
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. `'
jct- 4rT V tcc Pikl��(V i
Type or pri me Title or Authority
-2-/w /tea
gn re Date �
I, rl ! a Notary Public of the County of
State of Q�I�> "�`�hL Cy)" ;2 hereby certify that
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s). rr
Witness my hand and notarial seal, this A day of r'L v , 20y�.
My Commission expires ly
n
Commonwealth of Pennsylvania - Notary Seal
MARY E. LORD, Notary Public
Delaware County
My Commission Expires April 26, 2023
Commission Number 1205638