NCC216742_FRO Submitted_20211207

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 and/
or fax information unavailable, place NIA in the blank.)
Part A.
Apex Ap Public SafetyStation #36
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Apex
Highway/street Wimberly Road Latitude 35.7570 Longitude-78.9165
1 Approximate date land -disturbing activity will commence: Fall 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public/institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.4 AC
6. Amount of fee enclosed: $ 260 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dennis Brown E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Apex [phone]
Name Telephone
P.O. Box 250 73 Hunter Street
Current Mailing Address
Apex NC
City State
10, Deed Book No. 018543
Current Street Address
27502 Apex
Zip City
00852
919-249-3305
Fax Number
NC 27502
State Zip
Page No. Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Town of Apex [e-mail]
Name
P.O. Box 250
Current Mailing Address
Apex NC 27502
City State Zip
Telephone [phone]
E-mail Address
73 Hunter Street
Current Street Address
Apex NC 27502
City State Zip
Fax Number 919-249-3305

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed game. If the Financially Responsible
Party is a Corporation, 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
Telophon
Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Catherine Crosby
Type or prii rri
Signature
Town Manager
Title or Auth . rit
y
Date
I, -:3ynA-esQ _�) • , a Notary Public of the County of Nash
State of North Carolina, hereby certify that i t appeared
personally before me this day and being duly sworn acknowledged Viat the above form was
executed by him.
Witness my hand and notarial seal, this 3(a day of "_WC.ern)ar , 20 ) k
Jontesca D 511ver
1 — - — ­RSS0960068MOSSISFe ... J
Notary Publlo, Nash County, NO
My CornmIsslon Expires July 27 2022
Seal
otary
My commission expires _`jl a', Qom_