NCC230298_FRO Submitted_20230217

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Washington PK-12
2. Location of land -disturbing activity: County Washington City or Township Plymouth
US641NC45 35.87289-76.69247
Highway/Street LatltUde(decimaldegrees) LOngltUde(decimaldegrees}
3. Approximate date land -disturbing activity will commence: 1 /1 /2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Educational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19
6. Amount of fee enclosed: $ 1900.00 . 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mike Konieczka E-mail Address [e-mail]
Phone: Office # 919-322-2220 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
County of Washington 252-793-5823
10
Name
116 Adams St
Phone: Office #
116 Adams St
Current Mailing Address Current Street Address
Plymouth NC 27962 Plymouth NC
City
State Zip City
Deed Book No. 294 Page No. 575
State
Mobile #
27962
Zip
Provide a copy of the most curt deed.
6P �I

Part
". yCompany(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).
11//aSP/LNG-rv�'-Cyvn-T Ir C Y1077�5R �? wASef ca vC. �2G
Company Name E-mail Address
ao PA too 1 1 6 AO.4•n s s 7-
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # �,' 5d 74 S D 3 Mobile # 91q AyEq7-I
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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City
Mobile #
Name of individual to Contact (if Registered Agent is a company)
State Zip
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # 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.
G2S.
�C:)V/ Y I-A/rff/4&-E 2
Type or print name Title or Authority
G� )�zI5 did
Signature Date
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�E'►�-,C Col i i E a Notary Public of the County of WAS v-), ne) tjn
State of North Carolina, hereby certify that s . PD t —w - appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her,
Witness my hand and notarial seal, this i S day of D2cemver 20 a
E
No�EpuCOLtIFR
Public
Notary
��ah Carolina
y myres
MarMarch10202 My commission expires 31 i ! 202+c

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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
t nndowner 2 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
City State
Zip
City
State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone:
Office # Mobile #
Current Street Address
Current Mailing Address
City State
City
State Zip
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone:
Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Record:
Name
Current Mailing Address
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
City State Zip City
Deed Book No. Page No.
State Zip
Provide a copy of the most current deed.