NCC232302_FRO Submitted_20230801

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 East Washington St
2. Location of land-disturbing activity: County Guilford City or Township High Point
Highway/Stree:tEast Washington St Latitude(decimal degrees)_35.960994 L.ongitude(decimai degrees) -79.997980
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Municipal Roadway
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.13
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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name City of High Point E-mail Address [e-mail]
Phone: Office# 336-883-3194 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mt. Zion Baptist Church _ 336-887-3610
Name Phone: Office# Mobile#
PO Box 2541 753 Washington St
Current Mailing Address Cullelll Sbeet Address
High Point NC 27261 High Point NC 27260
City State Zip City State Zip
10. Deed Book No. 3213 Page No. 67 Provide a copy of the most current deed.
3435 377
3435 375
Note: This is a public linear roadway project where several properties have recorded
easements. See additional landowner information attached to this form and copies of
deeds provided.

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).
City of High Point [e-mail]
Company Name E-mail Address
P.O. Box 230 211 South Hamilton St
Current Mailing Address Current Street Address
High Point NC 27261 High Point NC 27261
City State Zip City State Zip
Phone: Office# 336-883-3194 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.
-ThEvo j2 SPENGEp t AI6,N EE( ING S5Qvl6E5 j2uzEtrh jL
Type or print name Title or Authority
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Si nature Date
I, Marrc,,r,ne S. Taniszcwslel, a Notary Public of the County of GV I I Pord
State of North Carolina, hereby certify thatcertify that --Tr-evor jipenC et- appeared personally
before me this day and being duly sworn acknowledged that fhe/ above form was executed by him/her.
Witness my hand and notarial seal, this c :9\day of reAruQ/'l./ , 20 23
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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:
City of High Point Board of Education 336-370-8100
Phone: Office# Mobile#
712 North Eugene Street 825 Washington St
Current Mailing Address Current Street Address
Greensboro NC 27401 High Point NC 27260
City State Zip City State Zip
Deed Book No. 2219 .Page No. 598 Provide a copy of the most current deed.
Landowner 3 of Record:
Pearson Memorial AME Chruch
Naive Phone: Office# Mobile#
105 Eccles Place 835 Washington St_
Current Mailing Address Current Street Address
High Point NC 27260 High Point NC 27260
City State Zip City Siaie Zip
Deed Book No. 1290 _Page No 81 Provide a copy of the most current deed.
2804 23
Landowner 4 of Record:
Betty T Phillips
Name Phone: Office# Mobile#
PO Box 2692 1003 Washington St
Current Mailing Address Current Street Address
High Point NC 27261 High Point NC 27260
City State Zip City State Zip
Deed Book No, 7563 _Page No 2747 Provide a copy of the most current deed.
Landowner 5 of Record:
Loving Care Cremations _
Name Phone: Office# Mobile#
PO Box 21164 1113 Washington St
Current Mailing Address Current Street Address
Winston Salem NC 27120 High Point NC 27260
City State Zip City State Zip
Deed Book No. 6114 _Page No. 1632 Provide a copy of the most current deed.
5897 1397
5897 1413

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:
Toussaint L'Ouverture Lodge
Name Phone: Office# Mobile#
519 Ellwood Dr 1215 Washington St
Current Mailing Address Current Street Address
High Point NC 27260 High Point NC 27260
City State Zip City State Zip
Deed Book No. 2993 _Page No. 78 Provide a copy of the most current deed.
Landowner 3 of Record:
City of High Point
Name Phone: Office# Mobile#
PO Box 230 119 Underhill St
Current Mailing Address Current Street Address
High Point NC 27261 High Point NC 27260
City State Zip City State Zip
Deed Book No._ 6261 _Page No._ 1584 _Provide a copy of the most current deed.
Landowner 4 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.
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.

Continued from Item I in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#