HomeMy WebLinkAboutNCC220387_FRO Submitted_20220131FINANCIAL 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 NIA in the blank.)
Part A. Philo Middle School
1. Project Name
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Location of land -disturbing activity: County Forsyth City or Township Winston-Salem
Highway/Street 410 Haverhill Latitude 35.05439 Longitude-80.24826
Approximate date land -disturbing activity will commence: September 1, 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.00 AC.
Amount of fee enclosed: $ 910.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eddie MacEldowney E-mail Address emac@dmp-inc.com
Telephone 336-819-5275 Cell # 336-312-4071 Fax ##
Landowner(s) of Record (attach accompanied page to list additional owners):
Winston-Salem/Forsyth Co. Board of Ed. 336-727-2816
Name Telephone Fax Number
P.O. Box 2513 475 Corporate Square Dr.
Current Mailing Address Current Street Address
Winston-Salem, NC 27102 Winston-Salem, NC 27105
City State
10, Deed Book No. 865
Zip City
Page No. 190
State
Zip
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.
Winston-SalemlForsyth Co. Board of Ed.
Name E-mail Address
P.O. Box 2513 475 Corporate Square Dr.
Current Mailing Address Current Street Address
Winston-Salem, NC 27102 Winston-Salem, NC 27105
City State Zip
Telephone 336-727-2816
City State Zip
Fax Number 336-661-6572
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.
Colon Moore
Typo -or int n m
Signature
Sheila R. Simpson
Director Construction Planning
Title or Authority
8-13-2021
Date
a Notary Public of the County of Forsyth
State of North Carolina, hereby certify that Colon Moore 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, this 13
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eal
PUt,Oc ;
day of August 2021
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My commission expires 2-1-2026