NCC230202_FRO Submitted_20230124

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 N/A in the blank.)
Part A.
1. Project Name GCS Visual Performing Arts PK-5 School Mass Grading Permit
2. Location of land -disturbing activity: County Guilford City or Township Greensboro
Randall Street 36.050670-79.758410
Highway/Street Latitude (decimal degrees) LOngltUde(decimal degrees)
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): 9.15
6. Amount of fee enclosed: $ 1,000 . 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 F. Gene Sides, Jr. E-mail Address [e-mail]
Phone: Office # 336-370-3490 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
GUILFORD COUNTY BOARD OF EDUCATION 336-370-3490 336-908-9283
Name Phone: Office # Mobile #
712 N. Eugene Street 712 N. Eugene Street
Current Mailing Address Current Street Address
Greensboro, NC 27401 Greensboro, NC 27401
City State Zip City State Zip
10. Deed Book No.002299 Page No.00650 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).
T.A. Loving Company [e-mail]
Company Name E-mail Address
3600 Glenwood Avenue, Ste 120 3600 Glenwood Ave. Ste 120
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
Phone: Office # 919-734-8400 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:
Edward T Jeffreys
Name of Registered Agent
E-mail Address
400 Patetown Rd
400 Patetown
Current Mailing Address
Current Street Address
Goldsboro NC 27530
Goldsboro NC 27530
City State Zip
City State Zip
Phone: Office # 919-734-8400
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
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
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 Parry). I agree to provide
corrected information should there be any change in the information provided herein.
E. Taylor Jeffreys
Chief Financial Officer
Type or print name Title or Authority
_._, September 15, 2022
Signatur(SDate
I, , a Notary Public of the County of Le-n of
State of No Carolina, hereby certify that E _ �{���n� P 4Y�0- tit`) appeared personally
before me this day and being duly sworn acknowledged that the above fo m was executed by him/her.
Witness my hand and notarial seal, this day of 20 a'a
Y Notary40A
0TqMy commission expires J

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.
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
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 4 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 5 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.

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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State 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 #