NCC241210_FRO Submitted_20240419

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. North SurryHigh School New One-Lane Drivewayand ParkingArea
1. Project Name 9
2. Location of land-disturbing activity: County Surry City or Township
Highway/Street US Route 89-W. Pine St Latitude 36.503944 Longitude -80.673175
3. Approximate date land-disturbing activity will commence: June 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.52 acres
6. Amount of fee enclosed: $ 600.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac= $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Robert Draughn E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Surry County Board of Education 336-386-8381
Name Telephone Fax Number
209 N. Crutchfield Street 2440 W. Pine Street
Current Mailing Address Current Street Address
Dobson NC 27017 Mount Airy NC 27017
City 208 State Zip City 170 State Zip
10. Deed Book No. 1840 Page No. 25n Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager maybe listed as the financially responsible party.
Surry County Board of Education [e-mail]
Name E-mail Address
209 N. Crutchfield Street 209 N. Crutchfield Street
Current Mailing Address Current Street Address
Dobson NC 27017 Dobson NC 27017
City State Zip City State Zip
Telephone[phone] Fax Number

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
Dr. Travis Reeves Superintendent
Type or rint name Title or Authority
1 3 �s-�`f
Signat Date
I, 1.1)2 ll J . EJ) O I 1 , a Notary Public of the County of 5VOsrcu
State of North Carolina, hereby certify that Tra-165 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notariail,�eal, this c 5 ,'day of kCX\ -�', 20 a`
° 6.?&110-1:t
NOTARY Notary
Seal. I U b L I C
My commission expires ID 151
i.11110,

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THIS DISBURSEMENT HAS BEEN APPROVED AS REQUIRED BY THE SCHOOL BUDGET AND FISCAL CONTROL ACT

*See Other Side For Opening Instructions*
SURRY COUNTY SCHOOLS
P.O. BOX 364
209 N. CRUTCHFIELD STREET
DOBSON, NC 27017
NCDEQ
NCDEQ
1617 MAIL SERVICE CENTER
RALEIGH, NC 276991617