NCC232955_FRO Submitted_20231010

FINANCIAL RESPONSIBILITY/OWNERSHIP FO Mept of Environmental Qualify
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION Ap
No person may initiate any land-disturbing activity on one or more acres as covered by thVAct9brif&03 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 compleMdj$ Kt roar rule
J
Regional Office. (Please type or print and, if the question is not applicable or the e-mail a•:re orWbtie
number is unavailable, place N/A in the blank.)
Part A.
1. Project NameTammy Lynn Center
2. Location of land-disturbing activity: CountyWake City or Township Raleigh
Highway/StreetCha ell Dr
PP Latitude(dmat decrees) 35'769335 Long ltude(decima!decrees) 78.685049
3. Approximate date land-disturbing activity will commence: 10/04/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):C°mmercial
5. Total acreage disturbed or uncovered (including off-site bottbw 8 .$waste areas): 1 .06
6. Amount of fee enclosed $200 + $500 The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example:8.10-acre application fee is$2,900). 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 Sarah Crawford E-mail Address [e-mail]
Phone: Office# 919.755.2672 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Board of Trustees of the Endowment Fund of NC State UnNersay 919.513.7997 919.513.7997
Name Phone: Office# Mobile#
PO Box 7001 Campus Box 7472
Current Mailing Address Current Street Address
Raleigh, NC 27695 Raleigh, NC 27695
City State Zip City State Zip
83
10. Deed Book No.2609 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.) tf the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(res).
Tammy Lynn Memorial Foundation, Inc. [e-mail]
Company Name E-mail Address
739 Chappell Dr, Raleigh, NC 27606 739 Chappell Dr, Raleigh, NC 27606
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Phone: Office# Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners 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) lithe 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) lithe 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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Stewart [e-mail]
Engineering firm or other consultant E-mail Address
Roy Lorenzen [phone] [phone]
Individual contact person (type or print) Phone: Office# Mobile#
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.
Sa , Cc w.tz-Cv.,4 Cue
ype or print nam Title or Authority
41) _ q-a - 3.3
ignature Date
I, JAB (AJ44 1,61-e , a Notary Public of the County of 1pJ Art(
State of North Carolina, hereby certify that -S VA-1-1- 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 2s day of S c'"i'vee, 20 2 3
to,
t �, °w,C, Notary
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'mi " 0TAR , ^�itri
Seal c My commission expires 1 0 ' f 1 .2 7
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