NCC230216_FRO Submitted_20230125

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 New Kiser Middle School
2. Location of land -disturbing activity: County Guilford City or Township Greensboro
Highway/Street Westover Terrace Latltude(decimal degrees) 36.087 Longitude(decimal degrees)_ -79.8 17
3. Approximate date land -disturbing activity will commence: September 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): 17.00 AC
6. Amount of fee enclosed: $ 1,700.00 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 F. Gene Sides, Jr. E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Guilford County Board of Education N/A
Name
712 N Eugene Street
Current Mailing Address
Greensboro NC
City State
10. Deed Book No.
1923
Phone: Office #
Same
Current Street Address
27401 Same
Zip
Page N
City
406
State
N/A
Mobile #
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(ies).
Metcon, Inc.
Company Name
763 Comtech Drive
Current Mailing Address
Pembroke NC 23372
City State Zip
Phone: Office # [phone]
E-mail Address
Same
Current Street Address
Same
City State zip
N/A
Mobile #
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:
Thomas ALAM7 �p%nl g 6� rkoh Ix, G®ii
Name of Registered Agent
763 Comtech Drive
Current Mailing Address
Pembroke NC 23372
City
State Zip
E-mail Address
Same
Current Street Address
Same
City
Phone: office # [phone] Mobile #
N/A
Aaron K. Thomas
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:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Thomas A. Plant
vice President
Type or,ame Title or Authority
10-11-2022
Signatu Date
---------------------------------- -
I,
q `Y\ , a Notary Public of the County of
State of North Carolina, hereby certify t �-11bUD 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 day of O 20325t —2")�
JOHNNA DILLING
NOTARY PUBLIC
WAKE COUNTY, NC �'ary
Nypr 1swon Expires 10-12-2025 l
My commission expires J �C