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HomeMy WebLinkAboutNCC223431_FRO Submitted_20221004NC Department of Environmental Quality Received FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JUL 0 1 2022 SEDIMENTATION POLLUTION CONTROL ACT W'nstont Sa em No person may initiate any land -disturbing activity on one or more acres as covered by the Act be ore his orm and an acceptable erosion and sedimentation control plan have been completed and apprBV0q"h9L1fA Quality 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 N/A in the blank.) Part A. 1. Project NameCrossfield Taxiway — Package 2 Grading 2. Location of land -disturbing activity: County Guilford City or Township Greensboro 1000A Ted Johnson Parkway Highway/Street Latltude(decimal degrees) Longltude(decimal degrees) 3. Approximate date land -disturbing activity will commence:AUgust 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.):AVlattion 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 258 6. Amount of fee enclosed: $25,800 . The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: NameLorin Akins E-mail AddressAkinsL@gsoair.org Phone: Office # 336.665.5600 Mobile # 336.907.0540 9. Landowner(s) of Record (attach accompanied page to list additional owners): Piedmont Triad Airport Authority 336.665.5600 336,907.0540 Name Phone: Office # Mobile # 1000A Ted Johnson Parkway 1000A Ted Johnson Parkway Current Mailing Address Current Street Address Greensboro NC 27409 Greensboro NC 27409 City State Zip City State Zip 10. Deed Book No. Page No. Provide a copy of the most current deed. 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 or if the landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies). Piedmont Triad Airport Authority RosserA@gsoair.org Company Name E-mail Address 1000A Ted Johnson Parkway 1000A Ted Johnson Parkway Current Mailing Address Current Street Address Greensboro NC 27409 Greensboro NC 27409 City State Zip City State Zip Phone: Office # 336.665.5600 Mobile # 336.665.5694 Note: 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 erosion 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 NC 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: Office # 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. Type or print name a4; - Signature Dep,- , 0� CcnsFruclk,U✓1 Title or Authority (,- 3 0 - 2Z Date a Notary Public of the County of State of North Carolina, hereby certify that ► rjS appeared personally 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 da o"O{, 202z i\EnIHu qF •�`��. t�, Notary s�TARr ' f- WY (j) COMMISSION EXPIRES 1 W23i2O24 �V y 0" PUBL%c My commission expiresLID ID i2 Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record. - Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 5 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Continued from Item 9 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties. Attach copies of this page as needed to list all financially responsible parties. Company 2 Name Current Mailing Address City Phone: Office # Company 3 Name Current Mailing Address E-mail Address Current Street Address State Zip City State Mobile # E-mail Address Current Street Address City State Zip City Phone: Office # Mobile # Company 4 Name Current Mailing Address E-mail Address Current Street Address City State Zip City Phone: Office # Mobile # Company 5 Name E-mail Address Zip State Zip State Zip Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile #