NCC222215_FRO Submitted_20220615

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name Parkway Waste/Borrow Site
2. Location of land -disturbing activity: County Ashe City or Township Laurel Springs
Highway/Street Blue Ridge Parkway Latltude(dec;,,,ai de9�ee5)36.389902 Longltude(d.arnal degrees)-81.257969
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): State Road Project
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.10 acres
6. Amount of fee enclosed 700+1750 . 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, afterwhich 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 4 d No ❑
8, Person to contact should erosion and sediment control issues arise during land -disturbing activity. -
Name David Dry
Phone: Office # 336-846-4295
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Brenda Miller (ET AL)
Name
PO Box 1795
Current Mailing Address
Sparta NC
City State
10. Deed Book No. 425
Phone: Office # Mobile #
PO Box 1795
Current Street Address
28675 Sparta NC 28675
Zip City State Zip
Page No. 45 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).
Vannoy Construction, Inc
Company Name
PO Box 635
Current Mailing Address
Jefferson NC 28640
City
[e-mail]
E-mail Address
1608 Hwy 221 N
Current Street Address
Jefferson NC 28640
State Zip City
Phone: Office # 336-846-4295 Mobile # [phone]
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:
Vannoy Construction, Inc. [e-mail]
Name of Registered Agent E-mail Address
PO Box 635 1608 Hwy 221 N
Current Mailing Address
Jefferson NC 28640
City State Zip
Phone: Office # 336-846-4295
Current Street Address
Jefferson NC 28640
City State Zip
Mobile # [phone]
Mark Vannoy
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 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)
(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:
BREC, PA
Engineering firm or other consultant
Justin Church, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
336-844-4088 828-773-6543
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.
Mark Vannoy
Typeor print namb
1�
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Signature
President
Title or Authority
Date
a Notary Public of the County of � S� e
State of North Carolina, hereby certify that ��CK 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 Z IS day of M F:4u , 20 Z Z
Jl-e�L W 2fkL
Notary
My commission expires 3-30 ZO z7