NCC230470_FRO Submitted_20230223

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name HL-0028 (US-401 & Mill Creek) Intersection Improvements
2. Location of land -disturbing activity: CountWake y City or Township Town of Fuquay Varina
US 401 /Mill Creek Drive 35.601-78.753
Highway/Street LatltUde(decimaldegrees) LOngltUde(decimaldegrees)_
3. Approximate date land -disturbing activity will commence: December 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal Infra.
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.570 acre
6. Amount of fee enclosed $700 . 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, afterwhich 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Matthew Poling E-mail Address mpoIing@a fuquay-varina.org
Phone: Office # 919-753-1035 Mobile # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Fuquay-Varina 919-753-1035 N/A
Name Phone: Office # Mobile #
134 N. Main Street 134 N. Main Street
Current Mailing Address Current Street Address
Fuquay-Varina, NC, 27526 Fuquay-Varina, NC, 27526
City State Zip City State Zip
10. Deed Book No. N/A Page No. N/A 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).
Town of Fuquay-Varina
Company Name
134 N. Main Street
Current Mailing Address
Fuquay-Varina, NC, 27526
[e-mail]
E-mail Address
134 N. Main Street
Current Street Address
Fuquay-Varina, NC, 27526
City State Zip City State Zip
Phone: Office # 919-753-1035 Mobile # N/A
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
(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:
Kimley-Horn and Associates, Inc
Engineering firm or other consultant
Bryan Vickery
Individual contact person (type or print)
[e-mail]
E-mail Address
919-653-2905 N/A
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.
Matt Poling
Type or print name
Signature
Engineering Director
Title or Authority
9/26/22
Date
I,Q�Y>rlD�i l Y 1G�W , a Notary Public of the County of
State of North Carolina, hereby certify that A 16, 9 t n(1 appeared personally
before me this day and being duly sworn acknowledged that the above fdrm was executed by him/her.
Witness my hand and notarial seal, this day of `(N 20 L a
Hannah Shaw
NOTARY PUBLIC
Wftgounty, NC
My Commission Expires December 07,, 2026
CA
n�
Notary
My commission expires a'
i/ -ov)'6

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.
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 1 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
Current Mailing Address
City State
Phone: Office #
Company 4 Name
Current Mailing Address
City State
Phone: Office #
Company 5 Name
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Street Address
Zip City State
Mobile #
E-mail Address
Zip
Current Street Address
Zip City State Zip
Mobile #