NCC240230_FRO Submitted_20240126

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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.
Pilot Mountain State Park-Bean Shoals Access,Crossing Improvements and Home Creek Stream Restoration
1. Project Name
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Surry City or Township Pinnacle
Hauser Road 36.26504 -80.48909
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 3/1/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Restoration
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 13.3
6. Amount of fee enclosed: $ 1 ,400 . 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 El
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brandon Spaugh E-mail Address b•[e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
PILOT MTN STATE PARK
Name Phone: Office# Mobile#
1792 PILOT KNOB PARK RD 1792 PILOT KNOB PARK RD
Current Mailing Address Current Street Address
PINNACLE NC 27043 PINNACLE NC 27043
City State Zip City State Zip
10. Deed Book No. 00296 Page No. 0495 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).
North State Environmental, Inc [e-mail]
Company Name E-mail Address
2889 Lowery St. 2889 Lowery St.
Current Mailing Address Current Street Address
Winston Salem NC 27101 Winston Salem NC 27101
City State Zip City State Zip
Phone: Office# 336 725-2010 Mobile#[phone]
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:
STEPHANIE WESTMORELAND [e-mail]
Name of Registered Agent E-mail Address
2889 Lowery St. 2889 Lowery St.
Current Mailing Address Current Street Address
Winston Salem NC 27101 Winston Salem NC 27101
City State Zip City State Zip
Phone: Office# 336 725-2010 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.
STEPHANIE WESTMORELAND President
Type or print name Title or Authority
cA€431z- L. Is /a.o a'f
Signature Date
I, i/&t 1)-7�-•�arirk-,o a Notary Public of the County ofLu I-6-')e-
State of North Carolina, hereby certify that c f erk).. 1 2 C. kit S+morc hnrl 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 5 day of JarIt ni , 20 21-1-
_ q462,t, eaar)
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KELLY L BOHANNON Notary L
NOTARY PUBLIC
GULF*COUNTY,NO My commission expires n 1`7 ZU
my Conunission Expires 8-17-2025 r% �