NCC230844_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 and/
or fax information unavailable, place NIA in the blank.)
Part A. SHEPHERD ELEMNTARY SCHOOL
1. Project Name
2. Location of land -disturbing activity: County IREDELL City or Township MOORESVILLE
Highwav/Street CHARLOTTE HWY Latitude35.63575 Longitude-80•$2963
3. Approximate date land -disturbing activity will commence: TBD
4. Purpose of development (residential, commercial, industrial, institutional, etc.): EDUCATIONAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.87 AC
6. Amount of fee enclosed: $ 600 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name SCOTT HALER E-mail Address [e-mail]
Telephone [phone]
Cell## 704-978-2067 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
IREDELL STATESVILLE SCHOOLS 704-978-2067
Name
Telephone Fax Number
350 OLD MURDOCK RD
350 OLD MURDOCK RD
Current Mailing Address
Current Street Address
TORUTMAN NC 28166
TORUTMAN NC 28166
City 1 gate Zip
City67 State Zip
10. Deed Book No. 2842 Page No.
75 Provide a copy of the most current deed.
2656
1624
Part B. 1731
1403
1. Company(ies) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
IREDELL STATESVILLE SCHOOLS
[e-mail]
Name
E-mail Address
350 OLD MURDOCK RD
350 OLD MURDOCK RD
Current Mailing Address
Current Street Address
TORUTMAN NC 28166
TORUTMAN NC 28166
City State Zip
City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent Email Address
Current Mailing Address Current Street Address
City
Telephone
State Zip
City
Fax Number
State Zip
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
SGo-r' dt-
Type or print name
Signature
Title or Authority
/1.30 •2ozZ
Date
C
a Notary Public/of the County of
State No Carolina, hereby certify that appeared
personally before me this day and being duly sworn ack wledged that the above form was
executed by him.
Witness,my4Eopo,and notarial seal, this jd !—!day of 20
NO -IA N ary
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