NCC232072_FRO Submitted_20230711

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name NEW PARKING LOT PROJECT
2. Location of land-disturbing activity: County NEW HANOVER City or Township WILMINGTON
Highway/Street 1740 AIRPORT BLVD Latitude 34°16'7 23"N Longitude 77°54'49.08"W
3. Approximate date land-disturbing activity will commence: SEPTEMBER/OCTOBER 2023
4. Purpose of development(residential,commercial, industrial, institutional,etc.): AIRPORT
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 7.86 ACRES
6. Amount of fee enclosed:$ soo 00 . 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).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name G.Martin(Marty)Wynn,P E E-mail Address mwvnneavconinc.com
Telephone [phone] Cell# 910-612-6900 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
WILMINGTON INTERNATIONAL AIRPORT 910-341-4125
Name Telephone Fax Number
1740 AIRPORT BLVD 1740 AIRPORT BLVD
Current Mailing Address Current Street Address
WII MINGTON NC 28405 WII MINGTON NC 28405
City State Zip City State Zip
10. Deed Book No. 817 Page No. 868 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.
WILMINGTON INTERNATIONAL AIRPORT FLYILM COM
Name E-mail Address
1740 AIRPORT BLVD 1740 AIRPORT RI Vn
Current Mailing Address Current Street Address
WILMINGTON NC 28405 WILMINGTON NC 28405
City State Zip City State Zip

Telephone [phone] Fax Number
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:
NIA
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:
NJA
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.
GRANSEUR DICK. P E,C M. DEPUTY AIRPORT DIRECTOR-OPERATIONS&FACILITIES
Type o print name Title or Authority
0/2 02 3
Signature Date
I, No SC (Vl, 1J6kvo ,a Notary
Public of the County of ea,J P'Z A00.d
State of North Carolina, hereby certify that 6-YGix1S etA r- iC) — appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him. ))� I `"t���auuuwuurrHN„ 4�''
Witness my hand and notarial seal,this l(i day of C'-1 ,20 QOrj M �� �y
Ro/gAAl1 DiAm)
NoTARy
Notary PueLic
My commission expires 2i 19- d-6 9ij,
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