NCC222148_FRO Submitted_20220613

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 N/A in the blank.)
Part A.
1. Project Name Wayne Christian School - Phase 2
2. Location of land -disturbing activity: County W6 .. _ City or Township Goldsboro
Highway/Street Patetown Road Latitude 35,417550 Longitude-77.963757
3. Approximate date land -disturbing activity will commence: June 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3 acres
6. Amount of fee enclosed: $ 300 . 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).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott T. Anderson. P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 252-258-0734 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wayne Christian School, Inc. 919-735-5606
Name Telephone Fax Number
1201 Patetown Road 1201 Patetown Road
Current Mailing Address Current Street Address
Goldsboro NC 27530 Goldsboro NC 27530
City State Zip City State Zip
10. Deed Book No. 1463 Page No. 653 Provide a copy of the most current deed.
Part B. 2824 460
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.
Wayne Christian School, Inc.
Name
1201 Patetown Road
Current Mailing Address
1201 Patetown Road
Current Street Address
Goldsboro NC 27530 Goldsboro NC 27530
City State Zip City State Zip

Telephone [phone]
Fax Number
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 Current Street Address
City State Zip City State Zip
Telephone 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
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.
Dean Hightower
Type or print name
Signature
Yc 'S-" '7D_
Title or Authority
Date
I, '�a �n �t _ Ske a Notary Public of the County of
State of North Carolina, hereby certify that Dean Hightower 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 day of , 20_ as
f�JCu�n
.4 Notary
I aft � My commission expires U l/ a