NCC231456_FRO Submitted_20230515

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 N/A in the blank.)
Part A.
1. Project Name: Bertie High School Athletic Field Improvements
2. Location of land-disturbing activity: County: Bertie City or Township: Town of Windsor
Highway/Street: Latitude: 36.049191 Longitude: -76.972425
3. Approximate date land-disturbing activity will commence: Feb 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 257,000 sq ft
6. Amount of fee enclosed: $600.00. The application fee of $100.00 per acre (rounded up to the next
acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$900).
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 : Tim Riordan P.E. E-mail Address TriordanAchacompanies.com
Telephone [phone] Cell# 240-994-3746 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bertie County Schools 252-794-3034 N/A
Name Telephone Fax Number
716 US Highway13N 716 US Highway13N
Current Mailing Address Current Street Address
Windsor NC 27983 Windsor NC 27944
City State Zip City State Zip
10. Deed Book No. 180/473 Page No. 320/184 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible •arties on an attached sheet.) If the company or firm is a sole
pr 'etorshilid name oft'e owner or anager may be listed as the financially responsible party.
MEW //
oSMut11wa•d @ 1•uht.k►2.hc.vc 5 r, %°s.,
S koo.S E-mail Address r �,a .41 s
716 US Highway13N 716 US Highway13N ,02
Current Mailing Address Current Street Address 70 A..1A *saft:1
Windsor North Carolina 27983 Windsor North Carolina 27983
City State Zip City State . Zip
Telephone: [phone] Fax Number: N/A ,:.

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
01-is L . Sw+wl\w044 'Qv('erAxincle,A '
p or j:me Title or Authority
Signati re Date
il ,ly COX- a Notary Public of the County of 414;e,
State of North Carolina, hereby certify that Oj L_. PriplawoccL appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of NEOt ..- , 20 22.
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MY Ot
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