NCC241067_FRO Submitted_20240409

Check if this project is ARPA-funded ❑
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, including any activity
under a common plan of development of this size as covered by the NCGO1 permit, 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 Multi-Modal Trails I Horizons Park
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name below under
which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Forsyth _City or Township Rural Hall
Highway/Street 2835 Memorial Industrial School Rd.Latitude(dec.degrees) 36.23 Longitude(dec degrees) 80.23
3. Approximate date land-disturbing activity will commence: June 1 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): To develop multiple trail
paths within this section of the park, for public use.
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 719.117 sf/16.5 AC
6. Amount of fee enclosed: $ 1700.00 . 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 Mr. Christopher Weavil E-mail Address weavilcs( Forsyth.cc
Phone: Office# 336-703-2501 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Forsyth County Parks and Recreation 336-703-2501 336-345-2075
Name Phone: Office# Mobile#
201 N. Chestnut Street 201 N. Chestnut Street
Current Mailing Address Current Street Address
Winston-Salem, NC 27101 Winston-Salem, NC 27101
City State Zip City State Zip
10. Deed Book No. 1219 Page No. 1038 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)maybe listed as the financially responsible party(ies).
Forsyth County Parks & Recreation weavilcs(cilForsvth.cc
Company Name E-mail Address
201 N. Chestnut Street 201 N. Chestnut Street
Current Mailing Address Current Street Address
Winston-Salem. NC 27101 Winston-Salem NC 27101
City State Zip City State Zip
Phone: Office# 336-703-2501 Mobile#[phone]
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 corrected information
should there be any change in the information provided herein.
Chris Weavil I Director of Forsyth County Parks & Recreation
ye or prin na Tilor Authority
-t-rz . .a , ,acz,F
Signature Date
11 I IOtila 5 .. il if}f'6 n , a Notary Public of the County of For- +h
y
State of North Carolina, hereby certify that CI'kj.4 a- 'yj v1 I 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 22 day of }c br ua vi , 20 cOy
q)7GUO 5. InG/fir,
```�,ttttifiltr,� Notary
.. .Nor My commission expires * cp4, 2, 202�
q
7-o: A . ••• • ---
.G
't1ttttt"