NCC221875_FRO Submitted_20220527

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
Ouallity 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 NamePartners in Learning
2. Location of land -disturbing activity: CountyRowan— City or TownshipSalisbury
Highway/Street 1775 S. Manin Luther ftg Jr. Ave. Latitude(dadmal degre") 35.651300 Longitude(dedrml ftrem) -80.490248
3. Approximate date land -disturbing activity Will commence: May 11 th 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):7
6. Amount of fee enclosed: $700,00 _. The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8. 1 0-acre application fee Is $900).
Checksshould be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes [3 Enclosed N No (I
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity.,
NameDiane Gibbs
Phone: Office# 704-633-3121
E-mail Addressdiane@ rbsarch.com
Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Partners In Leaming Child Development Center Inc. 704-628-9020
Name Phone: Office # Mobile #
2386 Robin Rd
Current Maillng Address
Salisbury, NC 28144
City
Current Street Address
State Zip City
State
Zip
10. Deed Book No.1350 _ Page No829 —Provide a copy of the most current deed.

Part B.
1. Company(les) 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).
Partners In Learning Child Development Center Inc.
Company Name E-mail Address
2386 Robin Rd
Current Mailing Address
Salisbury, NC 28144
City State Zip
Phone: Office #704-628-9020
Current Street Address
city State Zip
Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, Include with this form
the landowners 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
E-mail 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 Rnanclally Responsible Party Is an Individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Carifficate af 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 attorney4n-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.
Norma Honeycuff
Type or print name
-4 , Al -A
Signhlure k3
Executive Director
Title or Authority
Date
I, B-oitic 5cjng,4 a Notary Publicof the Countyof IZOWaLn
ShAe of North Carolina, hereby certify that WOYWM Hqhcwc-u+I- appeared personally
before me this day and being duty sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial sea], this Z 5-t'�'Iday of 'Fe-bir iA co- �j 20_L2___
uml L'4 Suahol
Notary
Seal
My commission expires I I - Z L4, Z o -zS

Continued from Items 9 & 10 in Part A of the Financial ResponsibilitylOwnership Fon-n 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 ResponsibilitylOwnership 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 #