NCC241304_FRO Submitted_20240606

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 Kernersville Recreation and Event Center
*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 Kernersville
1223 Union Cross Road 36.097200 -80.080770
Highway/Street Latitude(decimal degrees) Long itude(decimal degrees)
3. Approximate date land-disturbing activity will commence:June 1 , 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Rec & Event Center
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10'66 acres
6. Amount of fee enclosed: $$1 ,100 . 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 E Enclosed ❑ No ❑x
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian Starkey E-mail Address [e-mail]
Phone: Office# 919-469-3340 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Town of Kernersville [phone] [phone]
Name Phone: Office# Mobile#
PO Box 728 134 E Mountain St
Current Mailing Address Current Street Address
Kernersville NC 27285 Kernersville NC 27284
City State Zip City State Zip
10. Deed Book No. 002626 Page No. 01 330 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).
Town of Kernersville [e-mail]
Company Name E-mail Address
PO Box 728 134 E Mountain St
Current Mailing Address Current Street Address
Kernersville NC 27285 Kernersville NC 27284
City State Zip City State Zip
Phone: Office# [phone] 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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
WithersRavenel [e-mail]
Engineering firm or other consultant E-mail Address
Brian H Starkey 919-469-3340 919-247-3065
Individual contact person (type or print) Phone: Office# Mobile#
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.
Curtis Swisher Town Manager
Type or print name Title or Authority
2 3
Signature Date
I, Kfikk R. t'bolc , a NotaryPublic of the Countyof
++ ��r'Jlrll�
State of North Carolina, hereby certify that 1�1t 1S SWIS/1P.r 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 11 ' day of Aril , 20 d13
OFFICIAL SEAL
KEITH R. HOOKER
Notary Public-North Carolina Notary
FORSYTH COUNTY
My Corrvrtqassipt9 gxpirea My commission expires 4- 2- a025

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.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address 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 Mailing Address Current Street Address
City State Zip City State 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 State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item I in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#