NCC231630_FRO Submitted_20230531

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name ECU Pedestrian Plaza - Phase 3
2. Location of land-disturbing activity: County Pitt City or Township Greenville
Beckwith Dr -77.363706
Highway/Street Latituderaeamar degrees)35.606933 LOngitUde(decimai degrees)
3. Approximate date land-disturbing activity will commence:April 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1.85
6. Amount of fee enclosed: $200 . 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).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed 1 No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael Talton E-mail [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
East Carolina University 252-328-6131
Name Phone: Office# Mobile#
E 5th St E 5th St
Current Mailing Address Current Street Address
Greenville NC 27858 Greenville NC 27858
City State Zip City State Zip
10. Deed Book No.000N40 Page No.00403 Provide a copy of the most current deed.

PartE.
—�-----�--1'-
Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
_ the""=,"~`s)°- - - -
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
East Carolina University
Company Name E-mail Address
E 5th St E 5th St Current Mailing Address Current Street Address
GFeeDV'NB NC 27858 Greenville NC 27858
City State Zip City State Zip
��5�-���-�1�1
Phone: O��# ~~- ~^-~ ~ '~ ' Mobile#
Note: If the Financially Responsible Party isnot the owner of the land 1obo disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and tn conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry,give name and street address oy the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City 8to1u Zip CRY State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent inocompany)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name cf Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Dfhue# Mobile#
Name nf Individual 10 Contact(if Registered Agent ioacompany)

(c) If the Financially Responsible Party is engaging in business under an assumed name,give name under
-- ----�------mhich-thsoomponyis-Doing-Business-As: -If the Financially Responsible Party isan individual,-General
' —
Partnership, or other company not registered and doing business under an assumed name,attach a copy
of the Certificate nf Assumed Name.
Company DBAName
The above information is true and correct tothe 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(s)
or his obomney'in-fact, or if not an individum|, by an officer, diractor, padner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). [ agree to provide
corrected information should there be any change in the information provided herein.
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Continued from Items 8 & /0in Part Am'the Financial ResponsibilitylOwnership Form for multiple
3wleos. Attach copies of this page an needed bn list all landowners. �
Landowner 2cfRecord:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No, Provide a copy of the most current deed.
Landowner 3ofRecord:
Nome Phone: Ofhcm# k8nbi|e#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide m copy of the most current deed.
Landowner 4ofRecord:
Name Phone: Of8ce# Mohile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy nf the most current deed.
Landowner bofRecord:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy cf the most current deed.

Continued from Item t/n Part f]of the'Financial ResponsibilitylOwnershio Form for multiple parties.
Attach copies of this page aa needed*o list all financially responsible parties,
Company 2Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Offion# K8obike#
Company 3Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# h1obiks#
Company 6Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#