NCC222850_FRO Submitted_20220810

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
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Project Name Davidson Charter Academy - Building Addition
Location of land -disturbing activity: County
Davidson
City or Township
Lexington
Highway/Street 500 Biesecker Road Latitude(decimal degrees) 35.8457 LongitUde(decimal degrees) -80.2689
Approximate date land -disturbing activity will commence: July 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.02 acres
Amount of fee enclosed: $ 1,400.00 . The application fee of $100,00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed to No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Jennifer Flury
Name Davidson Charter Academy E-mail Address [e-mail]
Phone: Office #
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DCA Lexington Properties, LLC
Name
500 Biesecker Road
Current Mailing Address
Lexington, NC 27295
City State Zip
[phone]
Phone: Office #
Current Street Address
City
State
Mobile #
Zip
10. Deed Book No. 2472 Page No. 0112 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
DCA Lexington Properties, LLC
Company Name
500 Biesecker Road
Current Mailing Address
Lexington, NC 27295
City State
Phone: Office # [phone]
jflury@davidsoncharter.o
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Davidson Charter Academy, Inc.
Name of Registered Agent
500 Biesecker Road
Current Mailing Address
Lexington, NC 27295
City State
Phone: Office # [phone]
[e-mail]
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
Christine England, Board Chair
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
By: Davidson Charter Academy, Inc., Member
By: Christine England
Type or print name
Signature
Vice -Chairman of Davidson Charter Academy, Inc.
Title or Authority
Date
I, arx P_v� F . AAtA&baLlr a Notary Public of the County of C4.i, 1
C�
State of North Carolina, hereby certify that E*iAj o n appeared personally
before me this day and being duly sworn acknowledged that the Bove form was executed by him/her.
Witness my hand and notarial seal, this G 2 day of &AAvS+- 20 22-
Seal
of ry
My commission expires 0 AdVp