NCC223763_FRO Submitted_20221107

Received -'
AUG 3 0 2022
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Winston-Salem
SEDIMENTATION POLLUTION CONTROL ACT Regional Office
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.) 2
Part A. 9OCKI- W9
1. Project Name Bridge Street Basin Replacement and Rehabilitation
2. Location of land -disturbing activity: County Rockingham City or Township Eden
Attachment Attachment A Attachment
Highway/Street Latltude(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 23.5
6. Amount of fee enclosed: $ 2,400 . 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 ❑ Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jon M. Mendenhall, City Manager E-mail Address [e-mail]
Phone: Office # [phone] Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SEE ATTACHED SPREADSHEET
Name Phone: Office # Mobile #
Current Mailing Address
City State
10. Deed Book No.
Current Street Address
Zip City
State
Zip
Page No. 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).
City of Eden
Company Name
308 E Stadium Drive
Current Mailing Address
Eden NC
City State
Phone: Office # 336-623-2110
E-mail Address
308 E Stadium Drive
Current Street Address
27288 Eden NC
Zip City State
Mobile # [phone]
27288
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.
Jon M. Mendenhall
Type or print name
IYA
Sign ture
City Manager
Title or Authority
Date
a Notary Public of the County of ftu(JL 6ryu_
State of North Carolina, hereby certify that Jun m• "nd �einbV L" ( appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this D I
day of JU I LI 20 'D :;'-
Notary
My commission expires 5 1 18 t a