NCC240626_FRO Submitted_20240301

Check if this project is ARPA-funded ❑
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 NCG01 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.
1. Project Name OLD SALISBURY ROAD REPAIRS
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County FORSYTH City or Township WINSTON-SALEM
OLD SALISBURY RD g )36.055129 Longltude�decimal degrees)-80.265773 EST
Highway/Street Latitude decimal de reel
3. Approximate date land-disturbing activity will commence: 6/5/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): CITY REPAIRS
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 '6
6. Amount of fee enclosed: $200 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 ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name NEIL R. ULDRICK E-mail Address [e-mail]
Phone: office# [phone] Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Winston-Salem N/A N/A
Name Phone: Office# Mobile#
PO BOX 2511 100 East First St
Current Mailing Address Current Street Address
WINSTON-SALEM, NC 27102 WINSTON-SALEM, NC 27101
City State Zip City State Zip
10. Deed Book No. Page No. 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).
CITY OF WINSTON-SALEM [e-mail]
Company Name E-mail Address
PO BOX 2511 100 East First St
Current Mailing Address Current Street Address
WINSTON-SALEM, NC 27102 WINSTON-SALEM, NC 27101
City State Zip City State Zip
Phone: Office# [phone] 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:
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.
Lee Garrity City Manager
Type or print name Title or A thori
. 4 .7-12/ ,73 02 3
Si nature Dat
I, ' kT)/n/ &ai 5 Ai , a Notary Public of the County of 2P,7
e/4_
State of North Carolina, hereby certify that Lee 3 6aietei appeared personally
before me this dayand beingdulysworn acknowledged that the alive form was executed byhim/her.
g
Witness my hand and notarial seal, this 0/0 day of /'l , 20 (1.0
,. �M• WAps'• Nr:e516;r.
VARY
My My commission expires A02 3
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Comm.EXP.
Dec.7,2023
PUB4\C
SY1 Fi COV

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.
Address?
Landowner 2 of Record:
ALVA HAYES N/A N/A
Name P e: Office# Mobile#
1518 OLD SALISBURY RD 518 OLD SALISBURY RD
Current Mailing Address Current Street Address
WINSTON-SALEM, NC 27127 WINSTON-SALEM, NC 27127
City State Zip City State Zip
Deed Book No. 3124 Page No. 2071 Provide a copy of the most current deed.
Landowner 3 of Record:
TODD A COOK N/A N/A
Name Phone: Office# Mobile#
3288 ROBINHOOD RD 1465 OLD SALISBURY RD
Current Mailing Address Current Street Address
WINSTON-SALEM, NC 27106 WINSTON-SALEM, NC 27127
City State Zip City State Zip
Deed Book No. 1980 Page No. 2600 Provide a copy of the most current deed.
Landowner 4 of Record:
TODD A COOK N/A N/A
Name Phone: Office# Mobile#
3288 ROBINHOOD RD 1455 OLD SALISBURY RD
Current Mailing Address Current Street Address
WINSTON-SALEM, NC 27106 WINSTON-SALEM, NC 27127
City State Zip City State Zip
Deed Book No. 1980 Page No. 2602 Provide a copy of the most current deed.
Landowner 5 of Record:
DOUGLAS H STEADMAN N/A N/A
Name Phone: Office# Mobile#
8185 WOOD ST 1468 OLD SALISBURY RD
Current Mailing Address Current Street Address
MOUNT PLEASANT, NC 28124 WINSTON-SALEM, NC 27127
City State Zip City State Zip
1 722
Deed Book No. Page No. 48 Provide a copy of the most current deed.

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 6 of Record:
DOUGLAS H & KRISTI STEADMAN N/A N/A
Name Phone: Office# Mobile#
8185 WOOD ST 1460 OLD SALISBURY RD
Current Mailing Address Current Street Address
MOUNT PLEASANT, NC 28124 WINSTON-SALEM, NC 27127
City State Zip City State Zip
Deed Book No. 1903 _ Page No. 758 Provide a copy of the most current deed.
Landowner 7 of Record:
DOUGLAS H STEADMAN N/A N/A
Name Phone: Office# Mobile#
8185 WOOD ST 1468 OLD SALISBURY RD
Current Mailing Address Current Street Address
MOUNT PLEASANT, NC 28124 WINSTON-SALEM, NC 27127
City State Zip City State Zip
Deed Book No. 1 722 Page No.48 Provide a copy of the most current deed.
Landowner 8 of Record:
MICHAEL R MARTIN ET AL N/A N/A
Name Phone: Office# Mobile#
1412 OLD SALISBURY RD 1412 OLD SALISBURY RD
Current Mailing Address Current Street Address
WINSTON-SALEM, NC 27127 WINSTON-SALEM, NC 27127
City State Zip City State Zip
Deed Book No, 1886 Page No. 3396 Provide a copy of the most current deed.
Landowner 9 of Record:
ANDREW CARROS ET AL N/A N/A
Name Phone: Office# Mobile#
5360 NESTLEWAY DR 1415 OLD SALISBURY RD
Current Mailing Address Current Street Address
CLEMMONS, NC 2712 WINSTON-SALEM, NC 27127
City State Zip City State Zip
1298
Deed Book No. Page No. 1 781 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#