NCC223822_FRO Submitted_20221115

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:
1. Project Name: Pleasant Ridge Subdivision
2. Location of land -disturbing activity: 1819 Pleasant Ridge Road and 7201 Alcorn Road
3. Approximate date land disturbing activity will be commenced: April 1, 2022
4. Development type: Commercial_ Industrial_ Institutional_ MF residential ✓ SF residential ✓
5. Approximate acreage of land to be disturbed: 37.18Acres
6. Has an erosion and sediment control plan been filed? Yes No ✓
7. Landowner(s) of Record (attach pages to list additional owners)
Leoterra Pleasant Ridge LLC 336.967.6260 buddy.lyons@leoterrade,�
Name Telephone Email
110-A Shields Park Drive
Current Mailing Address
Kernersville North Carolina 27284
City State Zip
Current Physical Street Address
City State
8. Deed County: Guilford Book: 701/4890 Page: 195/1493
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Christopher Lyons
E-mail: [e-mail]
Part B:
Telephone: [phone]
Other: 336.671-1858
Zip
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.
Leoterra Pleasant Ridge LLC
Name
110-A Shields Park Drive
Current Mailing Address
Kernersville North Carolina 27284
City State Zip
336.967-6260 buddy.lyons@leoterradEn
Telephone Email
Current Physical Street Address
City State
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:
Name Telephone Email
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 Telephone Email
Current Mailing Address Current Physical Street Address
City State 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.
Christopher Lyons
Typ I
or pr name
Si ature
Manager
Title or Authority
Date
I, Rolae.c-� Y-ye Rkr\�V a Notary Public of the County of mer, 0,e \6L.!
State of Nof�L CAMI;rq hereby certify that ���S�olaner Lyon 5
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s).
Witness my hand and notarial seal, this'9}? day of NovP-+�� , 20 ate_.
My Commission expires g_I,f aOa3
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