NCC222032_FRO Submitted_20220531

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.
Project Name Brookford Road Sanitary Sewer Extension
2. Location of land -disturbing activity: County Forsyth City or Township Abbotts Creek
Highway/Street Brookford Road Latitude(decimai degrees) 36.1203 Longltude(decimai degrees). 80.0569
3. Approximate date land -disturbing activity will commence. ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public Sanitary Sewer
Line Installation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
3.4
6. Amount of fee enclosed $1.400.00 . The Express Permitting application fee is a dual charge. The
normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In
addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). 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 Chris Jensen
Phone: Office # 336-992-0206
E-mail Address ciensen(@toknc.com
Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Kernersville 336-992-0206
Name Phone: Office #
Mobile #
134 East Mountain Street (Easements and Property to be obtained by TOK)
Current Mailing Address Current Street Address
Kemersville ___NC 27284
City State Zip City State Zip
10. Deed Book No. N/A Page No. N/A 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).
_Town ok Kernersville
Company Name
134 East Mountain Street
Current Mailing Address
Kernersville NC 27284
cswisher@tok_nc.com
E-mail Address
Current Street Address
City State Zip City
Phone: Office # 336-996-3121 � Mobile #
State Zip
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
Phone: Office #
Zip City State Zip
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 Zip
Phone: Office #
E-mail Address
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 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
(d) If 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:
_Alley, Williams, Carmen & King, Inc.
Engineering firm or other consultant
Mark Reich, P.E.
Individual contact person (type or print)
mreichAawck.com
E-mail Address
336-226-5534 336-213-1415
Phone: Office # Mobile #
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.
Curtis L. Swisher
Type or print name
Signature
Town Manager
Title or Authority
s-��-z z
Date
I, W�i Pria, a Notary Public of the County of S�
State of North Carolina, hereby certify that ���� (, 6W i3ku✓ 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 IT', day of M Am 20&2
TBETH PRICE��
NOTARY PUBLIC 4'2
FORSYTH COUNTY, NC Notary
My CORNIkIS w Exp M !- 5' L.rJ _1
Seal My commission expires Qarn rie✓ 5, 2U2Z

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 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
Current Mailing Address
City State
Deed Book No.
Landowner 4 of Record. -
Name
Current Mailing Address
City State
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office #
Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Zip City
_ Page No._
Mobile #
State Zip
Provide a copy of the most current deed.

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 State
Phone: Office # Mobile #
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 #