NCC215332_FRO Submitted_20210928

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
NoUersonay initiate any land -disturbing activity on one or more acres as covered by the Act before this form
aneptable erosion and sedimentation control plan have been completed and approved by the Land
Quction, 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.
1. Project Name Leeseville Safe Routes to School
2. Location of land -disturbing activity: County Wake City or Township_ Raleigh
Oneal Rd, Country Trail and Leesville Rd
Highway/Street Latitude 35.8928 Longitude-78.7167
3. Approximate date land -disturbing activity will commence: July 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Transportation
5. Total acreage disturbed or uncovered (includinq off -site borrow and wactP 1.6 Ac
6. Amount of fee enclosed: $ 165.00 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 S585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad Cantrell E-mail Address [e-mail]
Telephone [phone] Cell # 732-986-2993 Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached list
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. 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.
City of Raleigh _ rich ard. kelly(d,)raleighnc.gov
Name E-mail Address
PO Box 590 One Exchange Plaza, 8th Floor
Current Mailing Address Current Street Address
Raleigh, NC 27602 Raleigh, NC 27601
City State Zip City State Zip

Telephone [phone] Fax Number
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
Current Mailing Address
City
Telephone.
State
Zip
E-mail Address
Current Street Address
City State Zip
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:
Ruffin Hall
Name of Registered Agent
PO Box 590
Current Mailing Address
Raleigh, NC 27602
City State
Telephone
919-996-5575
Ruffin. [e-mail]
E-mail Address
222 West Hargett St
Current Street Address
Raleigh, NC 27601
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.
Richard L. Kelly, P.E.
Type or, rint n me
Signature
Engineering Services Director
Title or Authority
pG c G
Date
I V 1 3—a t l Mpbo l " Mye Notary Public of the County of Ll�� � }l r-.
i`, I�l 1
State of North Carolina, hereby certify that I �-�'1QiC� � e- appeared
personally before me this day and being duly sworn acknowledged that the a e form was executed
by him.
Witness my hand and notarial seal, this ��04 day of Q L 20 (:5C)
TA R o��
CVrnT. exp n
y, 2p22
C� r�bQ�P
Notary II(
My commission expires v_ 4 Jy Q a

9a. Landowner(s) of Record (attach accompanied page to list additional owners):
Farbod Hodjat
Name Tele hone
8517 Shadow Wood Place
Current Mailing Address
Raleigh, NC 27613
City State Zip
p
8517 Shadow Wood Place
Fax Number
Current Street Address
Raleigh, NC 27613
City State Zip
10a. Deed Book No, 017435 Page No. 01609 Provide a copy of the most current deed.
City of Raleigh Easement DB17666 PG846
9b. Landowner(s) of Record (attach accompanied page to list additional owners):
Springdale Estates Association
Name
8704 Hidden View Ct
Current Mailing Address
Raleigh, NC 27613
Telephone
0 Leesville Rd
Current Street Address
Raleigh, NC 27613
Fax Number
City State Zip City State Zip
10b. Deed Book No. 002769 Page No. 00760 Provide a copy of the most current deed.
City of Raleigh Easement DB17666 PG852
9c. Landowner(s) of Record (attach accompanied page to list additional owners):
Wake County Board of Education
Name Telephone Fax Number
1551 Rock Quarry Rd
0 Leesville Rd
Current Mailing Address
Current Street Address
Raleigh, NC 27610
Raleigh, NC 27613
City State Zip
City State Zip
10c. Deed Book No. 004139 Page No.
00332 Provide a copy of the most current deed.
City of Raleigh Easement DB17693 PG400
9d. Landowner(s) of Record (attach accompanied page to list additional owners):
Wake County Board of Education
Name
Telephone Fax Number
1551 Rock Quarry Rd
0 Pride Way
Current Mailing Address
Current Street Address
Raleigh, NC 27610
Raleigh, NC 27613
City State Zip
City State Zip
10d. Deed Book No. 013625 Page No.
01724 Provide a copy of the most current deed.
City of Raleigh Easement DB17693 PG419
9e. Landowner(s) of Record (attach accompanied page to list additional owners):
Wake County Board of Education
Name
Telephone
Fax Number

1551 Rock Quarry Rd
5115 Country Trail
Current Mailing Address
Current Street Address
Raleigh, NC 27610
Raleigh, NC 27613
City State
Zip
City State Zip
10e.
Deed Book No. 004139
Page No.
00332 Provide a copy of the most current deed.
City of Raleigh Easement DB 17693 PG428
9f.
Landowner(s) of Record (attach
accompanied page to list additional owners):
Eric S Campbell
Name
Telephone Fax Number
1113 Keith Rd
8609 Leesville Rd
Current Mailing Address
Current Street Address
Wake Forest, NC 27587
Raleigh, NC 27613
City State
Zip
City State Zip
10f.
Deed Book No. 017024
Page No.
02424 Provide a copy of the most current deed.
City of Raleigh Easement DB 17693 PG437
9g.
Landowner(s) of Record (attach
accompanied page to list additional owners):
Eric S Campbell
Name
Telephone Fax Number
1113 Keith Rd
8415 Oneal Rd
Current Mailing Address
Current Street Address
Wake Forest, NC 27587
Raleigh, NC 27613
City State
Zip
City State Zip
10g.
Deed Book No. 017024
Page No.
02424 Provide a copy of the most current deed.
City of Raleigh Easement DB 17693 PG442
9h.
Landowner(s) of Record (attach
accompanied page to list additional owners):
Telephone Fax Number
Name
Current Street Address
Current Mailing Address
City State Zip
City State
Zip
10h.
Deed Book No.
Page No.
Provide a copy of the most current deed.
9i. Landowner(s) of Record (attach accompanied page to list additional owners):
Name
Current Mailing Address
Telephone
Current Street Address
Fax Numl
City State Zip City State
10i. Deed Book No. Page No. Provide a copy of the most c