NCC240563_FRO Submitted_20240305

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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 C-130 MRO FACILITIES-CLEARING AND GRUBBING PHASE 1
2. Location of land-disturbing activity: County LENOIR City or Township KINSTON
Highway/Street 2780 JETPORT ROAD Latitude 35°70'49 40"N Longitude 77'35'53.87'W
3. Approximate date land-disturbing activity will commence: MARCH 2024
4. Purpose of development(residential,commercial,industrial,institutional,etc.): AIRPORT
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 68.90 ACRES
6. Amount of fee enclosed:$ 6,900.00 . 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$900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed J
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name G.Marty Wynn,P.E. E-mail Address mwynn©avconinc corn
Telephone [phone] Cell# 910-612-6900 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
NC GLOBAL TRANSPARK AUTHORITY 757-775-R1Rn
Name Telephone Fax Number
7780 JETPORT ROAD 2780 JETPORT ROAD
Current Mailing Address Current Street Address
KINSTON NC 211954 KINSTON NC 7Rn54
City State Zip City State Zip
10. Deed Book No. 1131 Page No. 965 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firrn(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
NC GLOBAL TRANSPARK AUTHORITY NCGTP©NCDOT GOV
Name E-mail Address
7780 JETPORT ROAD 27130.IFTPORT ROAD
Current Mailing Address Curre•
APPROVE F R PAYMENT
KINSTON NC 28054 KIN!
City State Zip City
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Vendor# �3CP 2 I O # G L# Amt$
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Document# a�13 a 3 5 Amt$
2-1 lGt Total $ %./?

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:
N/A
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:
N/A
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.
GAGE KING AIRPORT PROJECT MANAGER
Type or print name Title or Authority
L / q— 112212 i
Signature Date
I,j J LO, JYf Mi , a Notary Public of the County of Lc O/2
State of North Carolina,hereby certify that 64-66 ?5 /�� appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.Witness my hand and notarial seal,thisa J day of /?itlO/4,2/L/
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