NCC230569_FRO Submitted_20230315

DATE: February 10, 2023
ATTN: Mike Lawyer, CPSWQ
DEMLR
North Carolina Department of Environmental Quality
SUBJECT: Revised FRIO Form
Good afternoon,
Please accept the attached Financial Responsibility/Ownership Form as a revised copy for your
files for Harnett Regional Jetport's Terminal Building Site Improvement project. If additional
information is needed or if you have any questions, feel free to contact me at the email or phone
number listed below.
Regards,
Natalie D. Pusser
Harnett Regional Jetport I Airport Director
Office Phone: [phone] Cell: 910-890-0067
Online: [e-mail] www.harnett.org/
Address: 615 Airport Road j Erwin, N.C. 28339
Harnett
c o _u_N r v
HARNETT REGIONAL JETPORT
Attachment (5)

FINANCIAL RESPONSIBILITYlOWNERSHIP 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Harnett Regional Jetport: Terminal Building Site Improvement
2. Location of land -disturbing activity: Count yHarnett City or Township E rwi n
615 Airport Road 35.3795-78.7355
Highway/Street p Latitude{decimal degrees) LOng)tude(decimal degrees)
3. Approximate date land -disturbing activity will commence: 2/10/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Airport
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):3
6. Amount of fee enclosed: $ PAI D $300 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 ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Natalie D. Pusser E-mail [e-mail]
Phone: Office # 910-814-2740 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Harnett County 910-814-2740 910-890-0067
Name Phone: Office # Mobile #
Po Box 940 615 Airport Road
Current Mailing Address Current Street Address
Lillington, NC 27546 Erwin, NC 28339
City State Zip City State Zip
10. Deed Book No. 685 Page No. 774-775 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).
Harnett County
Company Name
PO Box 940
Current Mailing Address
Lillington, NC 27546
City
State Zip
[e-mail]
E-mail Address
615 Airport Road
Current Street Address
Erwin, NC 28339
City
State
Phone: Office # 910-814-2740 Mobile # [phone]
Zip
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
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
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). l agree to provide
corrected information should there be any change in the information provided herein.
Natalie D. Pusser
Type or print name
Signature
Anna C. Peele
Airport Director
Title or Authority
Date
a Notary Public of the County of
Harnett
State of North Carolina, hereby certify that Natalie D. Pusser appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by himlher.
Witness my hand and notarial seal, this 9
day of February 202023
Notary
My commission expires September 25, 2024

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 B 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #