NCC220172_FRO Submitted_20220126

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.)
Part A.
1. Project Name Hilltop Needmore Rd Elementary School (WCPSS #862-520)
2. Location of land -disturbing activity: County
Wake
City or Township Fuquay-Varina
Highway/Street Hilltop Needmore Rd Latitude 35.630115 Longitude-78.736993
3. Approximate date land -disturbing activity will commence: July 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): School
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11 AC
6. Amount of fee enclosed: $ 715.00 . 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 $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name William Hartley E-mail Address [e-mail]
Telephone [phone] Cell # 919-422-1867 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wake County Board of Education
Name
5625 Dillard Dr Crossroad Building 1
Current Mailing Address
Cary NC 27518
City State Zip
Town of Fuquay Varina
Name
401 Old Honeycutt Road
Current Mailing Address
919-588-3577 n/a
Telephone
Same
Current Street Address
Same
City State
[phone]
Telephone
Same
Curren( Street Address
Fax Number
wa
Fax Number
0
Fuquay Varina NC 27526 Same
City State Zip City State Zip
10. Deed Book No. 017243 Page No. 00256 Provide a copy of the most current deed.
017476 01136

Part B.
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 scale
proprietorship the name of the owner or manager may be fisted as the financially responsible party.
Wake County Board of Education
Name
5625 Dillard Dr, Crossroad Building 1
Current Mailing Address
Cary INC 27518
City State Zip
[e-mail]
E-mail Address
Same
Current Street Address
Same
City State Zip
Telephone [phone] Fax Number n a

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
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 Parry
is a Corporation, give name and street address of the Registered Agent:
n/a
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Mark Strickland
Chief Facilities and Operations Officer
Type or print name - Title or Authority
Signature Date
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Q7 — b 1. IV OE-tZ , a Notary Public of the County of ��✓ �
State of North Carolina, hereby certify that /1/'t/_k 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 A651(,S'7--_� , 20
SCOTT D LOWDER
NOTARY PUBLIC
Wake County
g �I North Carolina
T�Ay Commission Expires June 4, 2026
Nota /
My commission expires 6 `7`T