NCC222610_FRO Submitted_20220725

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. RCC Center for Workforce Development
1. Project Name
2. Location of land -disturbing activity: County Rockingham City or Township Wentworth
3.
4.
5.
Highway/Street IBC-651 County Home Road Latitude 36.389625 Long i+.ude -79.753742
Approximate date land -disturbing activity will commence: December 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.44
6, Amount of fee enclosed: 3 585 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 x No Enclosed x
8.
a
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Garrett Frank E-mail Address [e-mail]
Telephone [phone] Cell # 919-698-6883 Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Rockingham Community College 336-342-4261 x2213
336.349,9986
Name Telephone Fax Number
P.O. Box 38 215 Wrenn Memorial Drive
Current Mailing Address Current Street Address
Wentworth NC 27375 Wentworth NC 27375
GE
city State Zip City State Zips \MGQ��'F
10. Deed Book No. See below Page No. Provide a copy of the most cuM
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Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbinkxA vity+de
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole ooetorsrtr�
the name of the owner or manager may be listed as the financially responsible party.
Rockingham Community College [e-mail]
Name E-mail Address
P.O. Box 38 215 Wrenn Memorial Drive
Current Mailing Address Current Street Address
Wentworth NC 27375 Wentworth NC 27375
City State Zip City State Zip
Telephone [phone] x2213 Fax Number336-349-9986

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:
nla
Name
Current Mailing Address
city
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Tony Gunn
Name of Registered Agent
P.O. Box 38
Current Mailing Address
Wentworth NC 27375
City
Telephone
[e-mail]
E-mail Address
215 Wrenn Memorial Drive
Current Street Address
Wentworth NC 27375
State Zip City
Fax Number
State Zip
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.
Tony Gunn
Type or print name
Signature
Assoc. VP for Facilities & External Affairs
Title or Authority
Date
a Notary Public of the County of R� du_ ~ L�-1,L
State of North Carolina, hereby certify that ^! L+ appeared
personally before me this day and being duly swam acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this �n day of ` nr� Ct , 20_aL_
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Tt�.r -�"
�• •• ''•••. �. Notary
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