NCC216130_FRO Submitted_20211104

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS E PERMITTING OPTION 0B012007
No erson may a nitrate any lard-disturbing activity on one or more acres v the t b r '
thisform and an acceptable erosion and sedimentation control plan have been completed and approved
bythe Land QualitySection, N.C. Department of Environmental Quality, Submit the completed form to the
as appropriate Regional Office, (Please e type r print and, if the q�uestian is not applicable or the e-mail and/or
fax information unavailable, place N/A in the blank.)
Part A.
Reynolds_High School Stadiumi 1 . Pry ect Name
�' h an tOn-Safer
_ Location of land-disturbing activity: Count — _City or To nship�
Highway/Street1400 WNorthwest Blvd La#ktude - .250_Longitude, _ —
_ Approximate date land-disturbing activity will commence: F all 2021 -
4. Purpose of deveroprnerit (residential, Commercial, industrial, institutional etc. : t tIt ti l
5_08 (already permitted)
5_ Total acreage disturbed or uncovered (including off-site borrow and waste areas):
_ Amount of feeenclosed: 1 _ ������ � t ��i�n�
Express Permitting application fee is a dual charge.
The normal fee of 65_00 per acre is assessed without a ceiling amount. In addition, the Express
Perniitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000,00 (Example; 9 acres total is ,58 ). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to I DE R_
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8_ Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Colon Moor - ail r moor @ f .ki .n .0
3 - 7- ex34916
Telephone 336-4O33198 —
_ Landowner(s ) of Record (attach accompanied page to list additional owners):
WS/FCBoard of Education
Name Telephone Fax Number
PO Box 2513
Current Mailing Address Current Street Address
Winston-Salem , NC_27102
City State Zip City -- State Zip
1 0_ Deed Book No. _ _ Page No. Provide a copy of the most current deed.
PartB.
ompan (ies) or firms) who are financial!} responsible for the land-disturbing activity (Provide a
comprehensive fit of all responsible parties on an attached sheet.) It the company or firm is a sate proprietorship,
Me name of the owner or manager may be listed as the fin an is fly responsible party.
V‘I 5 /PC t4L)Cr°111-;a%
Name E-mail Address
Fo 50,‘ 495143
Current Mailing Address urrent Street Address
W ;11541-01Pai crt 6.44A AJC- ;1 I
°A
City State Zip City State
Telephoner _ _ _ Fax Number

•
_ ff the Fir�ar� iaN Responsible Party is not a resident of North Carolina, give name end street address
2of thi designated North Carolina Agent:
NameE-mail Address — —
LJrrent Mailing Address Current Street Address
City State Zip City State zip
—
Telephone Fax Number
if the Financially Responsible Party is a Partnership or other person en _ in business under an
assumed name. attach a copy of the Certificate of Assumed Name, if the Financially Responsible
Marty is a Corporation, give name and street address of the Registered Agent: P
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State zip
Telephone Fax Number
(c) In 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:
Engineering Firm or other consultant E-rnail Address
Individual contact person (type or print) Telephone 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 ible Person if an individual or his attorney-in-
fact, or if not an individual, by n officer, director, partner, or registered agent with the authority to execute
instruments for the FinanciaNy Responsible Person)- I agree to provide corrected information should there be
any change in the information provided herein.
Col • n . ore iii Director Construction Planning
T • - • r •r - t rya Title or Authority
Is
/ j_ . 1 1 10-22-21 •
i• 1 -' ?ram Date
.
-,
�, Sheila Simpson , a Notary Public of the County of Forsyth
State of North aroilna, hereby certifythat Colon Moore appeared personally
before me this day and being duty sworn acknowledged that the above fora was executed by him. . • .
Witness • October 0 1
my* , r �ar7al seal, this
day'41 elk a
ar MI.1 1), tlf 4 5111P b V A r...... si I i A 111111
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', isM Notes
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