NCC230915_FRO Submitted_20230403

FINANCIAL RESPONSIBILITY/OWNERSHIP STATEMENT
As per 15A NCAC 04B .0118 — The draft Erosion and Sediment Control Plans will not be approved until
an authorized statement of financial responsibility and ownership is submitted.
As per GS 113A-54.1(a) - If the applicant is not the owner of the land to be disturbed, the owner's written
consent for the applicant to submit a draft Erosion and Sediment Control Plan and to conduct the
anticipated land -disturbing activity must be submitted with this document.
1. Project Name: PPG High Point Expansion
2. Physical Address/Location:
Street Address: 201 Old Thomasville Rd
3. Latitude: 35.93367758
9
5.
City: High Point State: NC Zip: 27260
Longitude:-80.02886932
Approximate date land -disturbing activity will commence: 10/21/2022
Purpose of development (residential, commercial, industrial, etc.)
Industrial
6. Approximate acreage of land to be disturbed or uncovered: 3.17
7. Landowner(s) of Record (use blank page to list additional owners):
Ennis Flint Inc DBA PPG
Name
4161 Piedmont Parkway
Current Mailing Address
Greensboro, NC, 27410
City, State, Zip
1-800-331-8118
Telephone Number
Name
Current Mailing Address
City, State, Zip
Telephone Number
8. Indicate book and page where deed or instrument is filed (use blank page to list additional deeds
or instruments). Provide copies of Deeds with this submittal.
Book 7595
Page 1900-1903
Page
FinResFm. Page # 1

1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity:
Ennis Flint Inc DBA PPG
Name Name
4161 Piedmont Parkway
Current Mailing Address Current Mailing Address
Greensboro, NC, 27410
City, State, Zip City, State, Zip
1-800-331-8118
Telephone Number Telephone Number
2. Registered agent, if any, for the person or firm who is financially responsible:
Signature Mailing Address
Printed Name Telephone 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 if not an individual, by an officer, director, partner or attorney -in -fact, or registered
agent with 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.
Randv Krahn
Type or Print Name
+' ✓�� � Imo, -
Signature
Plant Manager
Title of Authority
'T iC-D--_�_
Date
a Notary Public of the County of &, ; A;� rJ , State of North
Carolina, do hereby certify that P-C kg lU ra ✓I , appeared personally before me
this day and being duly sworn acknowledged that the above form was executed by him.
Witness X band snd-notarial seaL this day of 5ep�eiMbe.' , 20 22
MATTHEW NIXON
Notary Public, North Carolina Notary Public
Guilford County r
My Commission Expires
SIZ 5/Zv 7 My commission expires: f 25 l ZD'.Z7
FinResFm. Page # 2