NCC220771_FRO Submitted_20220215

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 Environment and Natural Resources. (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 Name Clover Garden School
2. Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street Pagetmn Road Latitude 36.216392 Longitude-79.453915
3. Approximate date land -disturbing activity will commence: March 2021 —
4. Purpose of development (residential, commercial, industrial, institutional, etc.) Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):15.8
6. Amount of fee enclosed: $1,040.00 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Chad Huffines E-mail Address [e-mail]
Telephone [phone] Cell # 336.382.8120 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Clover Garden School Inc.
336.586.9440 n/a
Name
Telephone Fax Number
2454 Altamahaw Union Ridge Rd
n/a
Current Mailing Address
Current Street Address
Burlington NC
27217
n/a n/a n/a
City State
Zip
City State Zip
10. Deed Book No. 4014
Page No
033 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties
on an attached sheet):
Clover Garden School Inc.
[e-mail]
Name
E-mail Address
2454 Altamahaw Union Ridge Rd
Same
Current Mailing Address
Current Street Address
Burlington NC
27217
City State
Zip
City State Zip
Telephone [phone]
Fax Number n/a

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
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 attomey-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.
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Signature Date
�,�{�6 a Notary Public of the County of 0'6VfiC6
State of North Carolina, hereby certify thatappeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. nn
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