NCC230833_FRO Submitted_20230328

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 Holley Branch Stream Restoration
2. Location of land -disturbing activity: CountyAvery/Mitchell City or Township Spruce Pine
200 Mayland Dr 35.933069-82.016823
Highway/Street Latltude(decimalaegrees) LongltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: February 24, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Stream Restoration
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.3
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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Greg Jennings E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MAYLAND TECHNICAL INSTITUTE 8287657351
Name
P O BOX 547
Phone: Office # Mobile #
200 Mayland Drive
Current Mailing Address Current Street Address
Spruce Pine NC 28777 Spruce Pine NC 28777
City State Zip City State Zip
10. Deed Book No. 84 Page No. 486 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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Mayland Community College [e-mail]
Company Name E-mail Address
P O BOX 547 200 Mayland Drive
Current Mailing Address Current Street Address
Spruce Pine NC 28777 Spruce Pine NC 28777
City State Zip City State Zip
Phone: Office # 8287657351 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:
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)
(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.
Dr. John C.
Type in arr
SiQr(ature
President
Title or Authority
Date
a Notary Public
1 _--►
State of North Carolina, hereby certify that n
before me this day and being duly sworn acknowledged that the
Witness my hand and notarial seal, this /� day of
County of I
appeared personally
form was executed by him/her.
tom, 20C4—
�YViu�� � ■ l t/ �
My commission expires 41

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.
Landowner 2 of Record:
BOARD OF TRUSTEES MAYLAND COMMUNITY COLLEGE
Name
Phone: Office # Mobile #
P O BOX 547
200 Mayland Drive
Current Mailing Address
Current Street Address
Spruce Pine NC
28777
Spruce Pine NC 28777
City State
Zip
City State Zip
Deed Book No. 286
Page No.
1207 Provide a copy of the most current deed.
Landowner 3 of Record:
MAYLAND COMMUNITY COLLEGE
Name
Phone: Office # Mobile #
P O BOX 547
200 Mayland Drive
Current Mailing Address
Current Street Address
Spruce Pine NC
28777
Spruce Pine NC 28777
City State
Zip
City State Zip
Deed Book No. 276
Page No. 397 Provide a copy of the most current deed.
Landowner 4 of Record:
MAYLAND COMMUNITY COLLEGE TRUS
Name
Phone: Office # Mobile #
P O BOX 547
200 Mayland Drive
Current Mailing Address
Current Street Address
Spruce Pine NC
28777
Spruce Pine NC 28777
City State
Zip
City State Zip
Deed Book No. 4 1 9
Page No. 407 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.