NCC230342_FRO Submitted_20230207

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 Gardner Webb Amphitheater
2. Location of land -disturbing activity: County Cleveland City or Township Boiling Springs
Highway/Street S. Main St Latitude(decimai degrees) 35.2462 Longitude(decimei degrees)-81.6665
3. Approximate date land -disturbing activity will commence: January 2, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.52
6. Amount of fee enclosed: $ 300 . 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 David WaCaster E-mail Address [e-mail]
C*
Phone: Office # 704-406-3235
Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Gardner Webb University 704-406-4000
Name Phone: Office #
P.O. Box 997 110 S. Main Street
Current Mailing Address Current Street Address
Boiling Springs NC 28017 Boiling Springs NC
City State
10. Deed Book No. 1831
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Mobile #
28017
Zip City State Zip
Page No. 2884 Provide a copy of the most current deed.
Page 283
Page 287
Page 590
Page 2889
Page 585
Page 64

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).
Gardner Webb University [e-mail]
Company Name E-mail Address
P.O. Box 997 110 S. Main Street
Current Mailing Address Current Street Address
Boiling Springs NC 28017 Boiling Springs NC 28017
City State Zip City State Zip
Phone: Office # 704-406-3235 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:
Mike Hardin [e-mail]
Name of Registered Agent E-mail Address
P.O. Box 997 110 S. Main Street
Current Mailing Address Current Street Address
Boiling Springs NC 28017 Boiling Springs NC 28017
City State Zip City State Zip
Phone: Office # 704-406-3235 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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Davi , Wa
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Director of Operations for Facilities and Maintenance
Title or Authority
1111122
Date
I, &tllrwic Linne &mrns a Notary Public of the County of C1CV,-fond
State of North Carolina, hereby certify that �o`id >ui(i�iS�C% 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 _A5�(—day of JonuotA, 20 ,)3
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My commission expires
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