NCC216160_FRO Submitted_20211108

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. West Club Boulevard Corridor UtilityRehabilitation
1. Project Name _
2.
3
4
Location of land -disturbing activity: County Durham City or Township Durham
Highway/Street SR-1321, sR-1399, and sR-2600 Latitude See attachments Longitude See attachments
Approximate date land -disturbing activity will commence: March 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Improvements
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.4
6. Amount of fee enclosed: $ 910 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Don Greeley E-mail Address [e-mail]
Telephon
919.560.4381 Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NIA NIA NIA
Name Telephone Fax Number
NIA NIA
Current Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
10. Deed Book No. NIA Page No. N/A 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 Durham c/o Don Greeley [e-mail]
Name E-mail Address
101 City Hall Plaza 1600 Mist Lake Drive
Current Mailing Address
Durham, NC 27701
City State Zip
Telephone [phone]
Current Street Address
Durham, NC 27704
City State Zip
Fax Number 919.560.4479

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:
NIA NIA
Name E-mail Address
NIA NIA
Current Mailing Address
NIA
City State Zip
Telephone NIA
Current Street Address
NIA
City State Zip
Fax Number NIA
(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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
City
Telephone NIA
►►n
E-mail Address
NIA
Current Street Address
NIA
State Zip City State Zip
Fax Number NIA
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.
Don Greeley
Type or print name
Signature
Director of Water Management
Title or Authority
zf2
Date
a Notary Public of the County of , r
State of North Carolina, hereby certify that�r,�,,1c�_ �'y �, 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 day of 20
Seal
Notary
My commission expires