NCC222639_FRO Submitted_20220809

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Stacking Lane for Bolivia Elementary School
2. Location of land -disturbing activity: County Brunswick City or Township Bolivia
HI hwa /Street U S 17 Business Latitude decimal degrees) 34.07008° N 781"86° W
g y � � � LOngltude�decimai degrees)
3. Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 .21
6. Amount of fee enclosed: $ 200.00 . 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 ❑ Enclosed x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Craig Eckert [e-mail]
Phone: office # 910-253-1078
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Brunswick County Board of Education 910-253-2900 910-398-3815
Name
35 Referendum Drive NE
Current Mailing Address
Phone: Office # Mobile #
35 Referendum Drive NE
Current Street Address
Bolivia NC 28422 Bolivia NC 28422
City
State
10. Deed Book No. 2845I1260
Zip City
Page No. 325/557
State
Zip
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(ios).
Brunswick County Board of Education [e-mail]
Company Name
35 Referendum Drive NE
Current Mailing Address
Bolivia NC 28422
E-mail Address
35 Referendum Drive NE
Current Street Address
Bolivia NC 28422
City State Zip City State
Phone: Office # 910-253-2900 Mobile # [phone]
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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
City
NIA
E-mail Address
NIA
Current Street Address
NIA
State Zip City
Phone: Office # N/A Mobile # NIA
NIA
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
City
Phone: Office # N/A
NIA
NIA
E-mail Address
NIA
Current Street Address
NIA
State Zip City
Mobile # NIA
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
NIA
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.
Crajq Eckert
Ty p o print nam
Sig ture
Director of Capital Projects & Planning
Title or Authority
Date
a Notary Public of the County of �aly5lyze-�
State of North Carolina, hereby certify that OleR6 � 4T 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 / da r
4 MEGAN A. GFUSSETT
AChNotary Public, North Carolina
Brunswick County
My Comml8sion Expires
June 04, 2025