NCC231055_FRO Submitted_20230417

NC Department of
Environmental Quality
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Received
SEDIMENTATION POLLUTION CONTROL ACT NOV O 8 2022
No person may initiate any land-disturbing activity on one or more acres as covered by theM. ke�r� t is
form and an acceptable erosion and sedimentation control plan have been completed and a prove b�`�P
Land Quality Section, N.C. Department of Environmental Quality. Submit the complet&fir*)a k6=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.)
7 t)
Part A. KI' 2.0 23 ,6 1
1. Project Name Forbush Middle School Tennis Courts
2. Location of land-disturbing activity: County Yadkin City or Township Forbush
Highway/Street 1431 Falcon Road Latitude 36.141944 Longitude -80.554999
3. Approximate date land-disturbing activity will commence: December 01, 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.73ac
6. Amount of fee enclosed: $ 200.00 . 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 Jeff Adams E-mail Address ieff.adams(a)yadkin.k12.nc.us
Phone: Office# [phone] Mobile#[phone]
9. L-andowner(s)-of-Record-(attach-accompanied-page4o-list-additional-owners-): -
_Yadkin County _(336) 849-7910
Name Phone: Office# Mobile#
217 E. Willow Street
Current Mailing Address Current Street Address
Yadkinville NC 27055
City State Zip City State Zip
10. Deed Book No. 761 & 884 Page No. 44 & 223 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).
Yadkin County
Company Name E-mail Address
217 E. Willow Street
Current Mailing Address Current Street Address
Yadkinville NC 27055
City State Zip City State Zip
Phone: Office# [phone] 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.
Jeff Adams Director of Maintenance
Type or print name Title or Authority
/,/- �;?- 22
01
gnature Date
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a Notary Public of the County of Sc r r
State of North Carolina, hereby certify that Jeff Adams 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 20_'
Allfl-IwIl M012'1-4— /C-"/1 a
MI T CHELL TIIHOM;O LONG try
Notary Public
Sorry County, NC My commission expires