NCC221059_FRO Submitted_20220315

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 N/A in the blank.)
Part A. Wake Technical Community College - Public Safety Simulation Complex
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Wendell
Highway/Street 5401 Rolesville Road Latitude 35.806489 Longitude-78.418010
3. Approximate date land -disturbing activity will commence: Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.4 Acres
6. Amount of fee enclosed: $ 1400 , The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Daniel Edwards E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
THE TRUSTEES OF WAKE TECHNICAL COMMUNITY COLLEGE
919-866-5148
Name
Telephone Fax Number
9101 Fayetteville Road
Same as Mailing
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Same as Mailing
City State Zip
City State Zip
10. Deed Book No. 018023 Page No. 02062 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.
THE TRUSTEES OF WAKE TECHNICAL COMMUNITY COLLEGE
[e-mail]
Name
E-mail Address
9101 Fayetteville Road
Same as Mailing
Current Mailing Address
Current Street Address
Raleigh NC, 27603
Same as Mailing
City State
Telephone [phone]
Zip City
Fax Number
State
Zip

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 Name. 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
Telephone 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.
Type or pri t n me f` Title or Authority
Si_ re Date
I, X6" A -,a a Notary Public of the County of CAAk.
State of North Carolina, hereby certify that _3W_n,. , 737. (214 t appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this &I day 20Q_
DEBRA A LESTER
NOTARY PUBLIC Notary
WICOUNTY, N.C.
My Cron ExphmSr ivw1aca My commission expires lI j y I QOa N