NCC221876_FRO Submitted_20220517

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. Fu ua Varina Middle School
1. Project Name q y
2
3
4
5
6
7
8
9
Location of land -disturbing activity: County Wake City or Township Fuquay-Varina
Highway/Street 1201 Bowling Road Latitude 35.565402 N Longitude -78.801444 W
Approximate date land -disturbing activity will commence: JUne 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 40 Ac
Amount of fee enclosed: $ 2,600.00 . 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).
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]
Landowner(s) of Record (attach accompanied page to list additional owners):
Wake County Board of Education 919-588-3573
Name
5625 Dillard Drive Crossroads Bldg 1
Current Mailing Address
Cary, NC 27518
City State
10. Deed Book No. 18637
Telephone
Same
Current Street Address
Same
Zip City
Page No. 2627-29
State
n/a
Fax Number
Zip
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.
Wake County Board of Education [e-mail]
Name E-mail Address
5625 Dillard Dr. Crossroads Bldg 1 Same
Current Mailing Address Current Street Address
Cary, NC 27518 Same
City State
Telephone [phone]
Zip
City State Zip
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
N/A
Current Mailing Address
N/A
City
Telephone N/A
State Zip
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
(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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City
Telephone N/A
State Zip
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
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 & Operations Officer
Type t
Signature
Title or Authority
67116 1 LJ-6-1-
Date
l 6 G� , a Notary Public of the County of �Z
State of North Carolina, hereby certify that rylatk �5 1 L1� IG! tom( appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
rkL
Witness my hand and notarial seal, this day of 20 21
�&'L�CKAI E GRiF '
Notary Wake County
geai North Carolina
My commissi0 M Commission Expires Aug. 31, 2022