NCC222072_FRO Submitted_20220603

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 NIA in the blank.)
Part A.
1. Project Name Tar Heel School PK-8
2. Location of land -disturbing activity: County Baden City or Township Tar Heel
NC Hwy 87 W Latitude 34,736753 Lon itude decimal der-78.793755
Highway/Street {decimal degrees) g { gees)
3. Approximate date land -disturbing activity will commence: April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.6
12.1 ac + 3.5 ac= 15.6 ac
6. Amount of fee enclosed: $ 1,600.00*See letter 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. $1,200 + $400=$1,600
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jason Atkinson E-mail Address [e-mail]
Phone: Office # 910-862-4136 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bladen County Board of Education 910-862-4136 910-872-3349
Name Phone: Office # Mobile #
1489 US Highway 701 South 1489 US Highway 701 South
Current Mailing Address Current Street Address
Elizabethtown NC 28337 Elizabethtown NC 28337
City State Zip City State Zip
10. Deed Book No. Q0819 Page No. 1191 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Bladen County Board of Education [e-mail]
Company Name E-mail Address
1489 US Highway 701 South 1489 US Highway 701 South
Current Mailing Address Current Street Address
Elizabethtown NC 28337 Elizabethtown NC
City State
Phone: Office # 910-862-4136
Zip City
Mobile #
State
28337
Zip
Note: If the Financially Responsible Party is not the owner of the land to be 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 to 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 of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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 of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Jason Atkinson
rint name
vj-V�s'O Kj
Superintendent
Title or Authority
4128/22
Date
a Notary Public of the County of NC'L&
State of North Carolina, hereby certify that a n,.� lc.'.+�zo•J appeared personally
before me this day and being duly sworn ackn ledged that the above form was executed by him/her.
Witness my hand and notarial seat, this zday of , 20 2--Z-
Seal
♦N'+t rr
w *0TAAr s
Notary
My commission expires 10 1 5� 1pZ P

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Bladen County 910-862-6700
Name Phone: Office # Mobile #
PO Box 1048 201 East King Street
Current Mailing Address Current Street Address
Elizabethtown NC 28337 Elizabethtown NC 28337
City State Zip City State Zip
Deed Book No. 0680 Page No. 0523 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
City State Zip
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
City State Zip
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
City State Zip
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 9 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
State Zip
City State Zip City State Zip
Phone: Office # Mobile #