HomeMy WebLinkAboutNCC215444_FRO Submitted_20210930FINANCIAL 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. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Property Use along Rams Drive
2. Location of land -disturbing activity. County Forsyth City or Township Winston-Salem
HlghwaylStreet Research Pkwy/Rams Drive Latitude 36.090615 Longitude-80.231974
3. Approximate date land -disturbing activity will commence: 09/1 5/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.);
commercial property use
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.6 acres
6. Amount of fee enclosed: $ 455 . 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 $585).
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 Jason Kaplan E-mail Address jakaplan @ wakehealth.edu
Telephone 336-716-1977 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
WFIQ Holdings, LLC 336-716-1977
Name Telephone Fax Number
575 N. Patterson Avenue, Ste 550 0 S. Research Parkway
Current Mailing Address Current Street Address
Wintson-Salem, NC 27101 Winston-Salem, NC 27101
City State Zip City State Zip
10. Deed Book No. 003120 Page No. 03159 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):
WFIQ Holdings LLC jakaplan@wakehealth.edu
Name E-mail Address
575 N Patterson Ave Suite 550
Current Mailing Address Current Street Address
Winston-Salem NC 27101
City State Zip City State Zip
Telephone 336-716-1977 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
E-mail Address
Current Street Address
State Zip 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:
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.
Type or print name Title or Authority
9-`9/�/ 132
Sig ure Date
a Notary Public of the County of f�>� Ye- s
State of North Carolina, hereby certify that p�,e�,J appeared
personally before me this day and being duly sworn ackn wledged that the above form was
executed by him.
Witness my hand and notarial seal, this i 3 day of m 20 2,
Jill 0 Peters Notary
NOWY ftWbw13 PUBLIC l a
North Carolina My com sion expires
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