NCC221883_FRO Submitted_20220518

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Valle CruCls School
2. Location of land -disturbing activity: County Watauga City or Township Banner Elk
Highway/Street BrOadStOne Road Latltude(decimal degrees) 36.20881 -81.77367
Longitude(decirnal degrees)
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12'50 onSite
6. Amount of fee enclosed: $ 1,300.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Deron Geouque E-mail Address [e-mail]
Phone: Office # [phone] Mobile # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Watauga County Board of Education [phone] N/A
Name Phone: Office # Mobile #
175 Pioneer Trail 175 Pioneer Trail
Current Mailing Address Current Street Address
Boone, NC, 28607 Boone, NC, 28607
City State Zip City State Zip
10. Deed Book No. 2121 Page No. 135 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).
Watauga County [e-mail]
Company Name
814 West King Street
E-mail Address
814 West King Street
Current Mailing Address Current Street Address
Boone, NC 28607 Boone, NC 28607
City State Zip
Phone: Office # [phone]
City State Zip
Mobile # N/A
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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

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
City
Deed Book No._
Landowner 3 of Record:
Current Street Address
State Zip City State Zip
Page No. _ Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record:
Name
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
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
Current Mailing Address
City
Deed Book No.
Phone: Office #
Current Street Address
State Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.

(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
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.
Deron Geouque
Watauga County Manager
Type or print name Title or Authority
Signature Date
I, NkOn,iC C�SOCl a Notary Public of the County of �n10.� GZ�ga
State of North Carolina, hereby certify that _1-)LQ On Geol.!"� _appeared personally
before me this day and being duly sworn acknowledged that the ab ve form was executed by him/her.
Witness my hand and notarial seal, this �Q day of , 20
������ti�rrrrrrirriii ��bi1-:3LCt.- t � • 1"1,��'C�
Notary
My commission expires /2 - d2, - 2- 025
LIG
�� :

Continued from Item 1 in Part 8 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
Phone: Office # Mobile #
State Zip
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 #

THIS MIXTl-TONE AREA OF THE DOCUMENT CHANGES COLOR GRADUALLY AND EVENLY FROM DARK TO LIGHT WTTH THE DARKER AREAS AT THE TOR AND BOTTOM -
Watauga County
FINANCE OFFICE
814 West King Street - Room 216
Boone, NC 28607
[phone]
VOID AFTER 90 DAYS
Pay One Thousand Three Hundred Dollars and 00 cents ******
00102740
To The STATE OF NC-DEQ
Order Of DEPARTMENT E&SC
1612 MAIL SERVICE CENTER
RALEIGH NC 27699-1612
First National
Bank
Vendor Check Check
Number Date Number 60-1809
6234 04/06/2022 00102740 433
$1,300.00
THIS DISBURSEMENT HAS BEEN APPROVED AS REQUIRED BY THE
LOCAL GOVERNMENT BUDGET AND FISCAL CONTROL ACT.

Watauga County, Boone, NC 28607 Check Number: 00102740
Invoice Date Invoice Number Description Invoice Amount i
04/06/2022 1139304 SEDIMENTATION CONTROL-VALLE CR GL-506120 457000 $1,300.00 1
Vendor No.
Vendor Name
Check No.
Check Date
Check Amount
6234
STATE OF NC-DEQ
00102740
04/06/2022
$1,300.00

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