NCC223741_FRO Submitted_20221102

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 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 and/
or fax information unavailable, place NIA in the blank.)
Part A. Johnston Regional Airport Drainage Improvements
1. Project Name
2. Location of land -disturbing activity: CountyJohnston City or Township Smithfield
Highway/StreetSwift Creek Rd Latitude35.540938 Longitude-78.390326
3. Approximate date land -disturbing activity will commence: August 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Airport
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):2.1
6. Amount of fee enclosed: $195.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Phil Lanier
E-mail Address [e-mail]
Telephone[phone] cell
# NIA Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Johnston County Airport Authority
919-934-0992 NIA
Name
Telephone Fax Number
3149 Swift Creek Road
3149 Swift Creek Road
Current Mailing Address
Current Street Address
Smithfield NC 27577
Smithfield NC 27577
City State Zip
City State Zip
10. Deed Book No. 769 Page No.
783 Provide a copy of the most current deed.
Part B.
1. 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.
Johnston County Airport Authority
[e-mail]
Name
E-mail Address
3149 Swift Creek Road
3149 Swift Creek Road
Current Mailing Address
Current Street Address
Smithfield NC 27577
Smithfield NC 27577
City State Zip
City State Zip
Telephone[phone]
Fax Number NIA

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
NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State
Zip City State Zip
Telephone N/A
Fax Number NIA
(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
NIA
Name of Registered Agent
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State
Zip City State Zip
Telephone N/A
Fax Number NIA
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.
Phil Lanier
Airport Director
Type rint name Title or Authority
Signature Date
i, I_I e 1 e tq r' . S . rn m g IA �) , a Notary Public of the County of ��� )�Gyv
State of North Carolina, hereby certify that 1'�LL' C c4Lh uCv appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this aah"'day of rn n � , 20 Q 0
Notary
Seal O _ _a c , �r
My commission expires

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 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 and/
or fax information unavailable, place NIA in the blank.)
Part A. Johnston Regional Airport Corporate Hangar Site Development -Phase 1
1. Project Name 1
2. Location of land -disturbing activity: County `!Ohnston City or Township Smithfield
Highway/Street Swift Creek Rd Latitude 35.54 Longitude -?8.39
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Airport
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.0
6. Amount of fee enclosed: $ 130 -.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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Phil Lanier E-mail Address [e-mail]
Telephone [phone] Cello NA Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Johnston County Airport Authority 919-934-0992 NA
Name Telephone Fax Number
3149 Swift Creek Road 3149 Swift Creek Road
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
city State Zip City State Zip
10. Deed Book No. 769 Page No. 783 Provide a copy of the most current deed.
Part B.
1. 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.
Johnston County Airport Authority _phil.lanierQnxairport.com
Name E-mail Address
3149 Swift Creek Road
Current Mailing Address
Smithfield NC 27577
city
State Zip
Telephone [phone]
_3149 _Swift Creek Road
Current Street Address
Smithfield NC 27577
City State
Fax Number NA
Zip

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:
NA NA
Name E-mail Address
NA NA
Current Mailing Address
NA
City
Telephone NA
State Zip
Current Street Address
NA
City State Zip
Fax Number NA
(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:
NA NA
Name of Registered Agent
NA
Curren Mailing Address
NA
City
Telephone NA
State
Zip
E-mail Address -
NA
Current Street Address
NA
City State Zip
Fax Number NA
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.
Phil Lanier
Type or name
Signature
Airport Director
Title or Authority
-- Z
Date
I, H e If in L - 5 ! ro n4g 6S , a Notary Public of the County of
State of North Carolina, hereby certify that ?V\ze as nzc v „-_ _ appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 1 f�_ day of _ SC_Pt ci,,, 1Cv , 20:2 1
lf4'��i
NOS WRY
PUBLIC
rON CO
. U44f, X,
Notary
My commission expires 08 " ) s
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