NCC231468_FRO Submitted_20230517

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: Perquimans High School Track and Soccer Field
2. Location of land-disturbing activity: County: Perquimans City or Township: Town of Hertford
Highway/Street: Latitude: 36.1859 Longitude: -76.4775
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 [e-mail]
Telephone [phone] Cell # 240-994-3746 Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Perquimans County Schools 252-426-5741 252-426-4913
Name Telephone Fax Number
PO Box 337 411 Edenton Road Street
Current Mailing Address Current Street Address
Hertford NC 27944 Hertford 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 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.
Tanya Turner
Perquimans County Schools tanyaturner(a�pgschools.org
Name E-mail Address
PO Box 337 411 Edenton Road Street
Current Mailing Address Current Street Address
Hertford North Carolina 27944 Hertford North Carolina 27944
City State Zip City State Zip
Telephone: [phone] Fax Number: 252-426-4913

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.
Dr. Tanya Turner Superintendent of Perquimans County Schools
Type or print name Title or Authority
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Signature Date
I, /71 f(1 v ( ,r- foot , a Notary Public of the County of (1h O( f)
State of North Carolina, hereby certify that taoja-rarner appeared
personally before me this day and being duly sworn ackrldwledged that the above form was executed
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Witness my j1 �H notarial seal, this"711 L)day of NO to -Cr , 20
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