NCC220543_FRO Submitted_20220128

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 tax intormation u
n
Part A. Atlantic Ave WideningProject
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Raleigh
Highway/Street H'ghwoods to Now Hope church Rd Latitude 35. 8233 Longitude-78.6088
3. Approximate date land -disturbing activity will commence: April 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Transportation
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 10.0
6. Amount of fee enclosed: $ 650 . 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 Chad Cantrell E-mail Address [e-mail]
Telephone [phone] cell # 732-986--2993 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Easement info to be provided prior to approval
Name
Current Mailing Address
City
Telephone
Current Street Address
State Zip City
Fax Number
State Zip
10. Deed Boole 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 [e-mail]
Name
Current Mailing Address
Raleigh, NC 27602
City
State Zip
Telephone [phone]
E-mail Address
One Exchange Plaza
I
Current Street Address
Raleigh, NC 2760'1
City State:. r -t, Zip
Fax Number !`;y

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
E-mail Address
. ...... _.._._._
Current Mailing AddressV
City State Zip City
Telephone Fax Number
State Zip
(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 -City Manager [e-mail]
Name of Registered Agent E-mail Address
PO Box 590 222 West Hargett St
Current Mailing Address
Raleigh, NC 27602
City
Current Street Address
Raleigh, NC 27601
State Zip City
Telephone [phone]
Fax Number
State Zip
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. Engineering Services Director
j
e or � t name
Signature
Title or Authority
-?-
Date
I, q 'I �&M p � I 011 VC a Notary Public of the County of Q ��
State of North Carolina, hereby certify that 61 Q'1 Y 11 1 n1-) f e., 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 LA
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