NCC221493_FRO Submitted_20220418

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 NIA in the blank.)
Part A. Wingate UniversityFootball Field
1. Project Name 9
2
3
4
Location of land -disturbing activity County Union City or TownshipWingate
Highway/Street SR 1758 Latitude 34.995 Longitude-80.445
Approximate date land -disturbing activity will commence May 1, 2022
Purpose of development (residential, commercial, industrial. institutional, etc.): Instltutiona
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.7
6. Amount of fee enclosed: $ 300.00 . 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 Ned? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Glenda Bebber E-mail Address [e-mail]
Telephone [phone] cell # 704-506-5886 Fax #
9
10
Landowner(s) of Record (attach accompanied page to list additional owners)'
Wingate University 704-233-8000
Name
PO Box 159
Current Mailing Address
Wingate
City
Deed Book No 960
Telephone
315 E. Wilson Street
Current Street Address
NC 28174 Wingate NC
State
Zip City
Page No.490
State
Fax Number
28174
Zip
Provide a copy of the most current deed.
Part B.
I 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.
Wingate University [e-mail]
Name E-mail Address
PO Box 159 315 E. Wilson Street
Current Mailing Address Current Street Address
Wingate NC 28174 Wingate NC 28174
City State
Telephone [phone]
Zip
City
Fax Number
State
Zip

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Parry 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.
Rhett Brown [e-mail]
Name of Registered Agent
PO Box 159
Current Mailing Address
Wingate NC 28174
City State Zip
E-mail Address
315 E. Wilson Street
Current Street Address
Wingate NC 28174
City
Telephone [phone] Fax Number
State Zip
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.
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Type or print name Title or Authority
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Signature Date
1. _ 1?%G f,6'. V)Ie—\% , a Notary Public of the County of _�r;o tN
State of North Carolina, hereby certify that w'-�V, p.r- Sl\c *gm Floor m appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hwdia*,potarial seal, this
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Notary Public
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County
00-26-2023
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Notary
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