NCC223686_FRO Submitted_20221028

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. Piedmont High School Track
1. Project Name g
2. Location of land -disturbing activity: County Union City or Township Unionville
Highway/Street Sikes Mill Road Latitude35.094 Longitude-80.489
3. Approximate date land -disturbing activity will commence: October 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). 4.2
6. Amount of fee enclosed: $ 500.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900,00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
$. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dave Burnett E-mail Address [e-mail]
Telephone [phone] Cell # __ u4 ? ! { i -11 , (r_ Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Union County [phone]
Name
4.00 North Church Street
Current Mailing Address
Monroe NC
City State
10. Deed Book No. 7287
28112
Telephone Fax Number
400 North Church Street
Current Street Address
Monroe NC 28112
Zip City
Page No. 799
State
Zip
Provide a copy of the most current deed.
Part B.
1. 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.
Union County Board of Education
Name
400 North Church Street
Current Mailing Address
Monroe NC 28112
City State Zip
Telephone [phone]
E-mail Address
400 North Church Street
Current Street Address
Monroe NC 28112
City State Zip
Fax Number 704-296-3163

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:
Dave Burnett [e-mail]
Name of Registered Agent E-mail Address
400 North Church Street 400 North Church Street
Current Mailing Address Current Street Address
Monroe NC 28112 Monroe NC 28112
City
State Zip
Telephone [phone]
City State Zip
Fax Number 704-296-3163
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.
Dave Burnett
Type_7rint me �---�
Signature
UCPS Director of Facilities
Title or Authority
Date
I, V-41A. ,UA/t {JpJ a Notary Public of the County of �A, _AOA,
State of North Carolina, hereby certify that �uY t4 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 Jb
NOTARY
Pusyk
day of , 20 � Z
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Notary
My commission expires 5QLW �V�