NCC230809_FRO Submitted_20230324

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, inctuding any
activity under a comm3r plan of development of this size as covered by the NCG01 permit, before this form
a,,-d an acceptable erosion and sedimentation control plan have been completed and approved by the Land
au3lity Section, N.C. Department of Environmental Quality. Submit the completed forms to the appropriate
Regicnal Office. (Please type or print and, if the question is not appl'ica�cle or the e-mail address or phone
number is unava lab€e. piace N A in the blank.)
Part A.
1 Project NameAdministration and Nlaintenanc,e d_ For Town of Walnut Cave
i' Ii"1i-3
2. Location of land -disturbing activity: County Stokes City or TovunshipSauratown
H€hNa S.r.,
g y; t c.et LatltUd
Third 5t P.,;dec;mal ,,eyr=,s; 36.2968 Long itude,,je.,;m,, dpq,�er)-80.1416
3 Approximate date land -disturbing activity will comment.e: 3I1 I2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Governmental
5. TotaE acreage disturbed or uncovered (inctuding off -site borrow and wraste areas)1 •55
6. Amount of fee enclosed: $200.0D . 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 NCtDEQ.
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 E-mail Address
Kim Greenwood to''Nr.maragergto,Niot/valnutcove.org
Phone: office # 336-591-4809 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Walnut Cove 336-591-4809
Name Prone: Office #
P4 Box 130 208 W Third St
Current Mailing Address
Walnut Cove NC 27052
Current Street Address
Walnut Cove NC
City State Zip City
1Q Deed Book No. Page Nc. _
1) 1 4- J,
State
336-403-3286
Mobile
27052
Zip
Provida a copy of t^e mast current deed.

Part B.
1. CompanyCes) who are financially responsible for the land -disturbing activity (Prove de a comprehensive list
of all responsible parties on accompanied page,) 1f the company is a sole proprietorship or if the landowrer(s1 �s
ar, irdividua!(V. the names) of the owner's) may be Listed as the finaocially responsible party(.!es)
Town of Walnut Cove [e-mail]
Company',lane E-mail Address
PO Box 130 208 W Third St
Current Mailing Address Curran! Street Address
Walnut Cove NC 27052 Walnut Cove NC 27052
City State Zip City State Zip
Phone: office # 336-591-4809 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:
Name of Registered Agent
Current Mailing Address
City Stale
Phone Office 4
E-mail Address
Current Street Address
Zip City
Mobile #
Marne of Individuai 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 flailing Address
E-mail Address
Current Street Address
City p `'iy
tat r`._
--
Stata 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 Respons;bie 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 IDBA Name
The above information is tr-e a-,-; correct to the best of my kno,,vledge and belief and was pro.,ided
by me under oath. (This form rru:- bte signed by the Financially Responsible Person if an individuals)
or his attorney -in -fact, or if not do individual, by an officer, director, partner, or registered agent wi`h
the authority to execute inst,-+_?rr ents for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Kim Greenwood
T e or print name
Signature
Town Manager
Title or Authority
3/ 13/20
Date
I, - 1��.���A� i'(� CZ .` , a Notary Public of the County et &f"D t
State of North Carolina, hereby certify that Kim Greenwood appeared persona?ly
before me this day and being duly sworn ackno�&,Iadged that the above form 'o,,ss executed by him!her
Witness my hand and notarial seal, this `t day of L'i] CL,r 0,Y1 , 20
�;%MANOA L BRYANT
Notary Public Notary
Forth Caroiin�a
Sto<es Courts Idly commission expires r.yi