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HomeMy WebLinkAboutNCC223413_FRO Submitted_20221011WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT WAKENo person may initiate any land -disturbing activity on one or more acres as covered by the Wake County Unified Development Ordinance before this form and an acceptable erosion and COUNTY sedimentation control plan have been completed and approved by Wake County Department of NORTH C;AROLINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not applicable, place N/A in the blank.) Part A. 1. Project Name Duke Health - Garner Medical Office Building 2. Location of land -disturbing activity: Jurisdiction Garner (Wake Co. or Municipality) Highway/Street Timber Drive Latitude 35.685218 Longitude -78.601294 3. Approximate date land -disturbing activity will commence: July 2022 4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 18.5 acres 6. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name David Stout E-mail Address David.Stout@lechase.com Telephone 919-930-5218 Cell # 919-930-5218 Fax # 7. Landowner(s) of Record (attach accompanied page to list additional owners): Duke University Health System Inc. Name(s) Telephone Fax or E-mail address 310 Blackwell Street, FL 4 310 Blackwell Street, FL 4 Current Mailing Address Current Street Address Durham, NC 27701 Durham, NC 27701 City State Zip City State Zip 8. Deed Book No. 018406 Page No. 01744 Provide a copy of the most current deed. Part B. 1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on an attached sheet. Include requested information): Duke University Health System Inc. Kevin. Houghton@duke.edu Name E-mail Address 310 Blackwell Street, FL 4 Current Mailing Address Current Street Address Durham, NC 27701 City State Zip City State Zip Telephone 919-414-9381 Fax Number 2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land Disturbance Permit: t 1 C'ti i r1 Lou ��U^ Name S`i2 6 f a')j Ge'1i4 Ag6 n Current Mailing Address Aotp r NC U500. City State Zip Telephone cf! 9- y1N- 1301 ��t . �� �� e- O."he. ed"I E-mail Address Current Street Address City Fax Number State Zip (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 Current Mailing Address City State Telephone E-mail Address Current Street Address Zip City State Zip 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. C eUin A Type or print name �'A A AM bl��' Signature Title or Authority Date 5 1v.-a'j- I, JAk, a Notary Public of the County of State of Nort Carolina, hereby certify that Vl appeared personally before me this day and being duly sworn acknowledged that t e bove form was executed by him. Witness my hand and notarial seal, this u' " 'day of20✓-