NCC240372_FRO Submitted_20240214

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.)
P1.art A.Project Name DE Benton Maintenance Building
2. Location of land-disturbing activity: County Wake City or Township Raleigh
Highway/Street Benson Road Latitude 35.66467 Longitude-78.60453
3. Approximate date land-disturbing activity will commence:December 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Utility (Water& Sewer)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.2
$200(Previously Provided)+$100 $100
6. Amount of fee enclosed: $ '"cluded=$soo total . The application fee of 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Breanne Long, PE E-mail Address [e-mail]
Telephone [phone] Cell# Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Raleigh 919-996-3732 919-996-1866
Name Telephone Fax Number
One Exchange Plaza, Suite 700 One Exchange Plaza, Suite 700
Current Mailing Address Current Street Address
Raleigh NC 27601 Raleigh NC 27601
City State Zip City State Zip
10. Deed Book No.N/A(Raleigh R/W) 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 maybe listed as the financially responsible party.
City of Raleigh [e-mail]
Name E-mail Address
P.O. Box 590 222 West Hargett Street
Current Mailing Address Current Street Address
Raleigh NC 27602-590 Raleigh NC 27601
City State Zip City State Zip
Telephone [phone] Fax Number 919-996-1866

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
Marchell Adams-David [e-mail]
Name of Registered Agent E-mail Address
P.O. Box 590 222 West Hargett Street
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27601
City State Zip City State Zip
Telephone [phone] Fax Number 919-996-1866
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.
Whit Wheeler, P.E. Public Utilities Director
Type Or print,rfa rrd ( Title or Authority
: :. 1( /.1( - ' , tz ( 2_2,7 2-z_____
Signature Date
I, , a Notary Public of the County of Johnston
State of North Carolina, hereby certify that Whit Wheeler 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 (9o2.slay of December 20 22
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°`c�```�rzS .. �')6e;; Sarah Weisenburn
��`�pTgR '� Notary
Seal ' -
' A C = My commission expires 7/29/24
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