NCC215471_FRO Submitted_20211001

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Wayne Memorial Hospital
1. Project Name
2. Location of land -disturbing activity: County Wayne City or Township Goldsboro, NC
Highway/Street Wayne Memorial Dr. Latitude 35.40 Longitude -78.95
3. Approximate date land -disturbing activity will commence: August 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 .6 ac.
6. Amount of fee enclosed: $ 130.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7 Has an erosion and sediment control plan been filed? Yes No No Enclosed Yes
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Narne Andrew Adams E-mail Address [e-mail]
Telephone [phone]
Cell # 336-457-1706
Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wayne Health Corporation 919-736-1110 919-587-2976
Name Telephone Fax Number
PO Box 8001 2700 Wayne Memorial Dr.
Current Mailing Address
Goldsboro, NC 27534
City State
10. Deed Book No 1110
Current Street Address
Goldsboro, NC 27533
Zip City
Page No. 218
State
Zip
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Wayne Health Corporation (William Thoma) [e-mail]
Name E-mail Address
2700 Wayne Memorial Dr, 2700 Wayne Memorial Dr.
Current Mailing Address
Goldsboro, NC 27534
City State
Telephone [phone]
Current Street Address
Goldsboro, NC 27534
Zip City State Zip
Fax Number919-587-2976

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number
State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone_
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Jessie L. Tucker, III
pe or print name
Siahature
L Kimberly Fazio
President and CEO
Title or Authority
7/16/2021
Date
a Notary Public of the County of Wayne
State of North Carolina, hereby certify that Jessie L.
personally before me this day and being duly sworn
executed by him.
Witness my hand and notarial seal, this
(0 KIMBERLY KRISTEN FAZIO
Notft&blic, North Carolina
Wayne County
My Cp irn ss ❑n Expires
Tucker, III appeared
acknowledged that the above form was
16th day of July 20'1121
otary
My commission expires _