NCC232773_FRO Submitted_20230914

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 Disposal Site - Keith Fields
2. Location of land -disturbing activity: County Caswell City or Township
HW 86/Gatewood Rd 36.539941 N 79.400295 W.
Highway/Street Latltude(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: 10/01 /2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.99
6. Amount of fee enclosed: $ 100.00 . 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 Keith Fields E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Keith Allan Fields 434-250-2717
Name
145 Wentz Circle
Current Mailing Address
Danville, VA 24541
City
Phone: Office # Mobile #
213 Gatewood Road
Current Street Address
PROVIDENCE, NC 27315
State Zip City
State
Zip
10. Deed Book No. 641 Page No. 897 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).
Keith Allan Fields
Company Name
145 Wentz Circle
Current Mailing Address
Danville, VA 24541
City State Zip
Phone: Office #
[e-mail]
E-mail Address
213 Gatewood Road
Current Street Address
PROVIDENCE, NC 27315
City
State
Mobile # [phone]
Zip
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:
=may T /-f,E Z
Name of Registered Agent
Current Mailing Address
--)-73 7C,
City State Zip
E-mail Address
Current Street Address
City State Zip
Phone: Office/#�'y -= I I 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
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
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.
Keith Fields
Type or print name
Signature
Property Owner
Title or Authority
9/4/1-1-3
D to
city
I, pliy� S 0► 1�1� 11 i ng a Notary Public of the-Geanty-of bmw i I1 Q.
VA �n ► a
State of Pier i r, hereby certify that � IQ i yb 'F 1 e d S 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 SQ 4 tQ m bt i 20 13 _
Notary
ALYSSA L E315ELT MELLING
NOTARY PUBLIC
REGISTRATION # 8Q20469 My commission expires d U 3 01 tia Z 10
COMMONWEALTH OF VIRGINIA
MY COMMISSION EXPIRES p6/3 M26

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:
Karri Fields
Name
145 Wentz Circle
Phone:
Office # Mobile #
Current Mailing Address
Current Street Address
Danville, VA 24541
City State
Zip
City
State Zip
Deed Book No. 641
Page No. 897
Provide
a copy of the most current deed.
Landowner 3 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 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 1 in Part 8 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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
State Zip
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 #