NCC232850_FRO Submitted_20230921

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place N/A in the blank).
Part A:
1. Project Name: Ward Road Pipe Plant
2. Location of land-disturbing activity: Site is located at the entrance to the Wendover Industrial Park off of Ward 8
3. Approximate date land disturbing activity will be commenced: September 15,2023
4. Development type: Commercial_ Industrial i Institutional MF residential^SF residential
5. Approximate acreage of land to be disturbed: 9,69
6. Has an erosion and sediment control plan been filed? Yes i No
7. Landowner(s)of Record (attach pages to list additional owners):
Terracon Precast LLC 336.967.6260 Ichoiniere@terraconprea
Name Telephone Email
110 Shields Park Drive Suite A 110 shields Park Drive Suite A
Current Mailing Address Current Physical Street Address
Kemersville NC 28284 Kernersville NC 28284
City State Zip City State Zip
8. Deed County: Guilford Book: 8716 Page: 2007
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Laval Choiniere Telephone: [phone]
E-mail: [e-mail] Other:
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.
Terracon Precast LLC 336-967-6260 Ichoiniere@terraconpred
Name Telephone Email
110 Shields Park Dr Suite A 110 Shields Park Drive Suite A
Current Mailing Address Current Physical Street Address
Kernersville NC 28284 Kernersville NC 28284
City State Zip City State 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 Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
(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 Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
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.
Christopher L nsf Managing Member
Type or nt e Title or Authority
_i /) 7
Signs ure F,, Date //-;\3
I, Dana Sandknop , a Notary Public of the County of Guilford
State of North Carolina _, hereby certify that Christopher Lyons
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s).
Witness my hand and notarial seal, this 13 day of $tp' , 20 Z-? .
My Commission expires`` /ZI Z&/v./ .
„„,,1,III rrrry,,
•,NCTAR w:
G 4, PusuC o .<,4 2oer 26,
© coy .