NCC240253_FRO Submitted_20240130

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres ao covered bvthe/�tbefore this form
and an acceptable erosion and sedimentation control plan have been completed o ' approved by the Land
Quality Geot|on, 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 ie unavailable, place N/A in the b|onk.)
Part A.
1 Project Name: SEA-Tech High School 8C|F Grant Addition and Renovations
2. Location of land-disturbing activity: County: New Hanover City orTownship: CmaUeHoyne
Highway/Street 5301 Sidbury Rood, V@|rninqton, NC 28411
Latitudm(o,vm"o/nemmes) 34.331 Long itudmmamma/degrees) -77.888
3. Approximate date land-disturbing activity will commence: July 18, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.4on
O. Amount of fee enclosed: $ 300.00 . The application fee of$1OO.UO per acre(rounded
upto the next acre) ie assessed without o ceiling amount (Exornp|e: 8.1O-oore application fee io$SDO).
Checks should be addressed boNCDEQ.
7. Has an erosion and sediment control plan been filed? Yes [] Enclosed 0 No O
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kim Gordon E-mail Address: kimnbar|y.qovdonK@_nhoa.not
Phone: Office# 910-254-4087 Mobile# [phone]
0. Landowner(s) of Record (attach accompanied page to list additional owners):
New Hanover County Board ofEducation 910-254`4087
Name Phone: [)ffioe# yNobi|e#
O41O Carolina Beach Road
Current Mailing Address Current Street Address
VW|nninAton NC 28412
City State Zip City State Zip
10. Deed Book No.___5828___Page No.___.1563 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).
New Hanover County Board of Education kimberly.qordonnhcs.net
Company Name E-mail Address
6410 Carolina Beach Road
Current Mailing Address Current Street Address
Wilmington NC 28412
City State Zip
Phone: Office# 910-254-4087 Mobile#
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.
,lNd6--P-Sc/y Ass-. `j•. I. C>pE/'a-�ia,/S
Type or print name Title or Authority I
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Signature Date
I,Frar�-es C- n'1o(PS , a Notary Public of the County of ,ovev---
State of North Carolina, hereby certify that Ca ee_ a: -scrn 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 c2g day of , ,` , 20 z.3
Notary
My commission expires $L1/(o7.2,(o