NCC231365_FRO Submitted_20230519

4\4 fnv#438481/SEPT22 $300.00 75— gEe' J
NC DEPARTMENT OF ENVIROMENTAL QUALITY
0e127/2022 # Pages 1 FP1 DOC8851033
1/OWNERSHIP FORM ��_ s y•
.iON CONTROL ACT t-
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 N/A in the blank.)
Part A.1. Project Name Mount Airy Airport - Terminal Site Development
2. Location of land-disturbing activity: County Surry City or Township Mount Airy
Highway/Street Howard Woltz Jr. Way Latitude 36.4642 Longitude 80.5556
3. Approximate date land-disturbing activity will commence:March 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Airport Development
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):3.0
6. Amount of fee enclosed: $ 300 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
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 Parrish and Partners of North Carolina E-mail Address pharrigan©parrishandpartners.com
Telephone [phone] Cell# 336.858.0614 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mount Airy Surry County Airport ATTN:Airport Manager 336.386.3700
Name Telephone Fax Number
146 Howard Woltz Jr. Way 146 Howard Woltz Jr. Way
Current Mailing Address Current Street Address
Mount Airy, NC 27030-9020 Mount Airy, NC 27030-9020
City State Zip City State Zip
10. Deed Book No. Page No. 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.
Mount Airy- Surry County Airport Authority [e-mail]
Name E-mail Address
118 Hamby Road 118 Hamby Road
Current Mailing Address Current Street Address
Dobson, NC 27017 Dobson, NC 27017
City State Zip City State Zip
Telephone [phone] Fax Number 336.401 .8216

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
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.
George Crater Airport Manager
Type or print name Title or Authority
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Si atu Date
I, V1 C Ae 1/ , W)Ock . , a Notary Public of the County of ,6 Ll,,r rtio
State of North Carolina, hereby certify that Geo ! ► • &tier appeared
personally before me this day and being duly swan acknowledged that the above form was
executed by him.
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