NCC232214_FRO Submitted_20230727

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 N/A in the blank.)
Part A.
1. Project Name Roanoke Chowan Community Health Center
2. Location of land-disturbing activity: County Bertie City or Township_Aulander_
Highway/Street 114 Brick Mill Road Latitude(decimal degrees) 36.232 Longitude(decimal degrees) -77.102
3. Approximate date land-disturbing activity will commence: 01/01/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Medical Offices
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.0 AC
6. Amount of fee enclosed: $ 300.00 . 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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Nicholas Fitzgerald E-mail Address nicholas.fitzoerald arkconsultinggrouo.com
Phone: Office# 919-475-0430 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Roanoke Chowan Community Health Center, Inc,
Name Phone: Office# Mobile#
113 Hertford County High Road
Current Mailing Address Current Street Address
Ahoskie NC 27910
City State Zip City State Zip
10. Deed Book No. 998 Page No. 846 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).
Roanoke Chowan Community Health Center
Company Name E-mail Address
113 Hertford County High Road
Current Mailing Address Current Street Address
Ahoskie NC 27910
City State Zip City State Zip
Phone: Office# 252-558-088 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company)

(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
correctedc information should&A).€1J/7,11-
there be any change in the information provided herein. n
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Signature Date
I, P'CWLGA o, 5• t't l-U , a Notary Public of the County of eYr-Nc's;Pl
State of North Carolina, hereby certify that t 4\. ((2?c O/1,.Sr• 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 -10 day of VC�z��0-cir , 20 27-
S. a-CC-LI
3�:�,, AMANDA S HALL Notary
ill : Notary Public, North Carolina
c v i.t°._•�iI Hertford County
%�.i,ii� My Commission Expires I �l I .70Zc
January 11,2025 •
My commission expires