NCC233648_FRO Submitted_20231213

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 NameASU Innovation Campus Ph 1 CBEAR Mass Grading
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Watauga City or Township
775 Bodenheimer Dr 36.21416 -81.69444
Highway/Street Latitude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence:6/15/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Educational
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):20.83
6. Amount of fee enclosed: $2,1 OO.00 . 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 El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jeffrey I. Smith E-mail Address [e-mail]
Phone: office# 980-201-5511 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Board of Trustees of the Endowment Fund 828-262-8776
Name Phone: Office# Mobile#
PO Box 32126 438 Academy St, BB Dougherty, Rm 125
Current Mailing Address Current Street Address
Boone, NC 28608 Boone, NC 28608
City State Zip City State Zip
Page No.700
10. Deed Book No. 1249 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)maybe listed as the financially responsible party(ies).
Appalachian State University [e-mail]
Company Name E-mail Address
438 Academy St. Dougherty Admin Bldg. 438 Academy St, BB Dougherty, Rm 125
Current Mailing Address Current Street Address
Boone, NC 28608 Boone, NC 28608
City State Zip City State Zip
Phone: Office# 828-262-8776 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.
Sheri Everts Chancellor, Appalachian State University
Type or print name Title or Authority
$ .21 23
Signature Date
Dawn Antonucci , a Notary Public of the County of Watauga
Sheri Everts,Chancellor of Appalachian St limy
State of North Carolina, hereby certify that 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 2 1 day of A-p i t , 20 23
Ik.:.r.idi. emdbmisbabdo hwi Notary
DAWN ANTONUCCI
Nota10 btic•North Carolina 0
Watauga County I My commission expires 3 Z S 2 l0
My Commission Expires Mar 28, 2026

(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.
Daniel T. Layzel I Vice Chancellor of Finance&Operations,Appalachian State University
Typ print nam �,/� /to( Title or A thority
/4111
4,.e,
Sign11F re Dat
I, LC&.4 ` t S . Vita Cd , a Notary Public of the County of IA)&kaA q c1
State of North Carolina, herebycertifythat Daniel T. Layzell,VC of F&O,App St. Univ appearedv
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 2�t day of ATV t , 2023
7L( d
Lane S Moody r0
Ct
Notary Public Nota
Wataaj4County, NC
My Commission Expires Aug.7,2023 My commission expires 41 71 2 0 23

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:
Board of Trustees of the Endowment Fund 828-262-8776
Name Phone: Office# Mobile#
PO Box 32126 438 Academy St, BB Dougherty, Rm 125
Current Mailing Address Current Street Address
Boone, NC 28608 Boone, NC 28608
City State Zip City State Zip
Deed Book No. 1831 Page No.345 Provide a copy of the most current deed.
Landowner 3 of Record:
State of North Carolina(Appalachian State Univ) 828-262-8776
Name Phone: Office# Mobile#
438 Academy St, BB Dougherty, Rm 125 438 Academy St, BB Dougherty, Rm 125
Current Mailing Address Current Street Address
Boone, NC 28608 Boone, NC 28608
City State Zip City State Zip
Deed Book No.2286 Page No.087 Provide a copy of the most current deed.
Landowner 4 of Record:
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 5 of Record:
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.

Continued from Item 1 in Part B 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#