NCC243013_FRO Submitted_20241002

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 Pitt Community College, Welding Building
2. Location of land-disturbing activity: County Pitt City or Township_Winterville
Highway/Street_Reedy Branch_Latitude(decimaldegrees)_35.5552_Longltude(decimai degrees) 77.4105
3. Approximate date land-disturbing activity will commence: Jan 1, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Educational
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.70 Ac was 6.5 Ac.
6. Amount of fee enclosed: $ 100.00. 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 Ricky Brown E-mail Address_ wr em Thr o1 n- re/D+r.owtQ 3(C
Phone: Office# 252-493-7200 Mobile#
M,Y T r (�c . e al L.A.-
9 Landowner(s) of Record (attach accompanied page to list additional owners)
Pitt Community College 252-493-7200
Name Phone: Office# Mobile#
PO Drawer 7007 1986 Pitt Tech Road
Current Mailing Address Current Street Address
Greenville, NC 27835 _Winterville, NC 28590
City State Zip City State Zip
10. Deed Book No._346 _Page No._493 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).
Pitt Community College Isom poifowfJ 3(L @iy.pi HICC
Company Name E-mail Address
PO Drawer 7007 _1986 Pitt Tech Road
Current Mailing Address Current Street Address
Greenville, NC 27835 _Winterville, NC 28590
City State Zip City State Zip
Phone: Office# 252-493-7200 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.
Name-of-Registered-Agent E-mail-Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile#
A4anne-e Individual to Contact (if Registered Agent is a company)
Name—of-Registered Agent E mail Address
Current Mailing Address Current Street Addres.,
City State Zip City State Zip
Phone: Office it Mobile it
s 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.
NA
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.
Ricky B wn Chief Financial Officer
Type in ame Title or Aut ority
T� S z oZ�
Signatur Date
I, 4.A,t..k V Ckark , a Notary Public of the County of 'Pik-4
State of North Carolina, hereby certify that R't.ck 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 5' ' day of arc." , 20 Ai.
ub44ee0e044,,t, otary
My commission expires 5/1 °1/ao
Ca 6
e,
ipeses,�COt1 oae�� @,

Continued from !toms 9 & 1
Landowner-2 of Recor4
Name P-hone=-Offise-# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book-No. Page No. P-rovide-asopya
Name Mobile-#
Current Mailing Address Current Street Addreec
City State Zip City State Zip
Deed Book No. Page No. Provides copy-of the most current deed.
Name Pho;•ce#f Mob le#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provi
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Z4p
Deed Book No. Page No. Provide a copy of th

Company 2 Name E mail Address
Current-Mail+agAddress Current Street Addroce
City State Zip City State Zip
Rhone: Office it Mobile#
Company 3 Name E mail Addrecs
Gdrren-Mailing-Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company I Name E mail-Address
Current Mailing Address Current Street Addrecc
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E--mail-Address
Current Mailing Addrecs Current Street Address
City State Zip City State Zip
Rhone: Office-# Mobile#