NCC220759_FRO Submitted_20220215

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. Uwharrie Charter AcademyHigh School & Trades
1. Project Name g
2. Location of land -disturbing activity: County Randolph City or TownshipCedar Grove
Highway/Street 5154 US Hwy 220 Bus South Latitude N35.6294 Longitude W-79.8258
3. Approximate date land -disturbing activity will commence: February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): I nstitutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):23
6. Amount of fee enclosed: $4,300.00 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes Nox Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael Rhoades E-mail Address [e-mail]
Telephone [phone] cell # 919-607-2344 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Uwharrie Green School, Inc. 336-610-0818 336-610-0815
Name Telephone Fax Number
5154 US Hwy 220 Business South 5154 US Hwy 220 Business South
Current Mailing Address Current Street Address
Asheboro NC 27205 Asheboro NC 27205
City State Zip City State Zip
10. Deed Book No. 2484 & 2516 Page No. 880 & 1478 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 may be listed as the financially responsible party.
Uwharrie Green School, Inc. [e-mail]
Name
5154 US Hwy 220 Business South
Current Mailing Address
Asheboro
City
E-mail Address
5154 US Hwy 220 Business South
Current Street Address
NC 27205 Asheboro NC 27205
State Zip City
State
Zip
Telephone [phone] Fax Number 336-610-0815

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
City State
Telephone
Current Street Address
Zip City State Zip
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
(c) In 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:
CLH Design, pa kdowningC dVidesignpa.com
Engineering Firm or other consultant E-mail Address
Keith Downing 919-319-6716 919-319-7516
Individual contact person (type or print) 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.
Type or tint me Title or Authority
igna re Date
I, se"qe(N� V • T� a Notary Public of the County of Fo `\r�
State of North Carolina, hereby certify that C vvcNs WN'e'� appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 1) .k'tN day of � X%UVIM 20 2-Z
Beverly W. BrillPE
Notary Public a y
Seal Forsyth xpirr � �t� /Fj 1 D
Nip Commission kL�tims�.�l My commission expires 1' � '-•I/