NCC230871_FRO Submitted_20230329

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Reidsville High School Synthetic Turf Field Project
2
3.
Location of land -disturbing activity: County Rockingham City or Township Reidsville
1901 S. Park Dr 33.328464
Highway/Street LatltUde(decimal degrees) LongltUde(decimal degrees)
Approximate date land -disturbing activity will commence: March 1, 2023
-79.677180
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.5
6. Amount of fee enclosed $1050 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameLance Rosenberger E-mail Address)[e-mail]
Phone: Office # 704-660-3000 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rockingham County Schools 336-627-2657
Name
511 Harrington Hwy
Current Mailing Address
Eden NC 27288
Phone: Office # Mobile #
511 Harrington Hwy
Current Street Address
Eden NC 27288
City State Zip City
10. Deed Book No. 547 Page No. 475
501 729
547 477
State
Zip
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).
Geosurfaces Southeast, Inc
Company Name
150 River Park Rd
Current Mailing Address
Mooresville NC 28117
City
[e-mail]
E-mail Address
150 River Park Rd
Current Street Address
Mooresville NC 28117
State Zip City
Phone: Office # 704-660-3000 Mobile #
State
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:
CT Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office # 314-236-3932 Mobile #
Lars Fox
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Kevin E. Herring Engineering [e-mail]
Engineering firm or other consultant
Kevin Herring PE
Individual contact person (type or print)
E-mail Address
980-621-0935
Phone: Office # Mobile #
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 individ ual(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.
Lance Rosenberger
Type gKprint )
Signature
SVP Construction Services
Title or Authority
Date `
1, �!! F`6' O l/ , a Notary Public of the County of :Lm
State of North Carolina, hereby certify that 2-60Q_7 appeared personally
before me this day and being duly sworn acknowledged that the above'form was executed by him/her.
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Witness my hand and notarial seal, this day of a?aW 20 02_'j
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