NCC230115_FRO Submitted_20230113

NC Department of
�• Environmental Quality ;IVA
Received
kINANCIAL RESPONSIBILITY/OWNERSHIP FORM
' FEB 0 7 2020 SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
Winston-Salem
initiat .:Any land -disturbing activity on one or more acres as covered by the Act before this
i��AVSR �eptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A. Rental Car Facility Relocation Project - Phase 1 (Earthwork), Cut Site
1. Project Name
2. Location of land -disturbing activity: County Guilford City or Township Greensboro
Highway/Street Inman Road Latitude 36.1208 Longitude-79.9131
3. Approximate date land -disturbing activity will commence: May 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 44 Acres
$2860 + $2000 (express) = $4,860 total
6. Amount of fee enclosed: $ 4,860 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Brigid Williams, PE E-mail Address [e-mail]
Telephone [phone] Cell # 919-268-0834 Fax # [phone]
E
Landowner(s) of Record (attach accompanied page to list additional owners):
Piedmont Triad Airport Authority 336-665-5600 336-665-5694
Name Telephone Fax Number
1000A Ted Johnson Parkway 1000A Ted Johnson Parkway
Current Mailing Address
Greensboro NC
City State
10. Deed Book No. 6028, 3163
27409
Current Street Address
Greensboro NC 27409
Zip City State Zip
Page No. 0039 - 0041, 806 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
J. Alex Rosser, PE, Deputy Executive Director [e-mail]
Name E-mail Address
1000A Ted Johnson Parkway same
Current Mailing Address
Greensboro NC 27409
City State Zip
Telephone [phone]
Current Street Address
same
City State
Fax Number 336-665-5694
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
WK Dickson [e-mail]
Engineering Firm or other consultant E-mail Address
Brigid Williams, PE 919-256-5614 919-782-9672
Individual contact person (type or print) Telephone Fax Number
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.
J. Alex Rosser, P.E. Deputy Executive Director
Typ r )Ma na eL,__, Title or uthority
Sigri'afure Date
State of North Carolina, hereby certify that / 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 day of 20 l�
`,�,,,Ut1111111f gl/Ill�yi
Nota
r
0T/0 - - ��z
Mggj, Li My commission expires
commissiMYoN s
EXPIRES
� fa�vzo2, r
:gyp AVBLIG y
0
O e