NCC216291_FRO Submitted_20211112

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 and/or fax
information unavailable, place N/A in the blank.)
Part A.
1. Project Narne Northern Regional Hospital MOB
2. Location of land -disturbing activity: County Surry City or Township Mount Airy
Highway/Street S. South Street Latitude 36D29M 1 7.04S N Longitude 80D36M48.11M W
3. Approximate date land -disturbing activity will commence: October 2021
4 Purpose of development (residential, commercial, industrial, institutional, etc.): Medical Office Building
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas) _6.41 Acres
6. Amount of fee enclosed: $ 2,205 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting 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 $2,585).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brian Beasley E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners)
Northern Hospital District of Surry County 336-783-8353
Name Telephone Fax Number
P.O. Box 1101 830 Rockford Street
Current Mailing Address Current Street Address
Mount Airy NC 27030-1101 Mount Airy NC 27030
City State Zip City State Zip
01074, 01137, 0049, 0808
10 Deed Book No. 01254 Page No 0224 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.
Northern Hospital District of Surry County
Name
P.O. Box 1101
E-mail Address
830 Rockford Street
Current Mailing Address Current Street Address
Mount Airy NC 27030-1101 Mount Airy NC 27030
C ity
State Zip City
State
Zip

Telephone_ Fax Number
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number_ _
(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 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:
Timmons Group [e-mail]
Engineering Firm or other consultant E-mail Address
Adam Carroll. P.E- [e-mail]
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 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 Pei ation provided herein
I
Y�l'MLL i;C1�iCAD
Typ or Fri t n Title or Authority
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Sign tune Date
I. �Y let l a A i�S�'" a Notary Public of the County of
State of North Carolina, hereby certify that CV1/V t 5 A , L(.LrK<-oi e�l appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness ti '11PM%1Q*I seal, this _day of L + 20
NOTARY Ij t C.
z Notary
Seal s ,
PUBLNG �G My commission expires U