NCC223428_FRO Submitted_20221004

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
Duality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable. place NIA in the blank.)
Part A.
1. Project Name Davidson County Airport Authority - Sky Aviation Hangar Site
2. Location of land -disturbing activity: County Davidson City or Township Lexington
Highway/Streetr_"f On Way Latitude(deamal degrees) 35' 77 Long itudetder nw jegreW -$0.30
31 . A,pQ ayj af_ date- land- diViir.bnr3 ar-bu0� wilt. camma-oor-f . O ct o b e r 30 , 2 0 22
4
5
fi
Purpose of development (residential. commercial, industrial, institutional, etc.). Hangar Addition
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.69 acres
Amount of fee enclosed: $ 600.00 . The application fee of $990.00 per acre (rounded
up to the next acre} is assessed without a ceiling amount (Example: 8.1 0-acre application fee is $940).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 17x Enclosed ❑x No ❑
E:
0
Person to contact should erosion and sediment control issues arise during land -disturbing activity-
Name Karel Van Der Linden E-mail Address [e-mail]
Phone. office # 336-956-7774 Mobile # [phone]
Laser+ res4s; of 9"Fvzwr & S#,Vzzlh, Wzrzr..xr,,-,; 'i&- p� fe YFJ, a #. r,al vsimW).
Davidson County Airport Authority 336-956-7774
Name
PO Box 1067
Current Mailing Address
Lexington NC 27292
City State
10. Deed gook No. 944
Phone. office # Mobile #
1673 Aviation Way
Current Street Address
Lexington NC 27292
City State Zip
98 Page No. Provide a copy of the most current deed.
Zip

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship orif the landowner(s) is
an individual(s). the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Davidson County Airport Authority [e-mail]
Company Name
PC Box 1067
Current Mailing Address
Lexington NC
E-mail Address
1673 Aviation Way
Current Street Address
27292 Lexington NC
27292
City State Zip City State Zip
Phone: office # 336-956-7774 Mobile # [phone]
Nate- If the Financially Responsible Party is not the owner of the land to be disturbed. include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erasion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) if the Financially Responsible Party is a domestic company registered on the INC Secretary of State
business registry, 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
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) if the Financially Responsible Party is not a resident of North Carolina. give name and street address
of the designated North Carolina agent
who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City state
Zip City State Zip
Phone: ❑ffice #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) if the Financially Responsible Party is engaging in business under an assumed name. give name under
which the company is Doing Business As. if the Financially Responsible Party is an individual, General
Partnership. or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Rick Phillilps
Type or print name
Board Chairman
Title or Authority
� C�/�ti'ir7soN �t�.tJ7Lf i�-iPA�rT �t�.rrFl,�rrrr�t
5ignatur Date �
1"Z a Notary Public of the County of
",ea"d
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 11 day of 20V2
BRONWYN K. APPLE Notary
Notary Public
North Carolina My commission expires AILU
Davidson County