NCC222310_FRO Submitted_20220623

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. Millbrook Pre-k Building
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Raleigh
Highway/Street Millbrook Road Latitude35.84781 Longitude-78.61031
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): I nstitutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7 acres
6. Amount of fee enclosed: $ 700.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 William Hartley E-mail Address Whartley@wcpss. net
Telephone [phone] cell # 919-422-1867 Fax # [phone]
N
10
Landowner(s) of Record (attach accompanied page to list additional owners):
Wake County Board of Education 919-588-3573
Name
111 Corning Road, Suite 190
Current Mailing Address
Cary, NC 27518
City State
Deed Book No. 002046
Telephone
same
Current Street Address
same
Zip City
Page No. 00289
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 orfirm 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
111 Corning Road, Suite 190
Current Mailing Address
Cary, NC 27518
City State Zip
Telephone [phone]
E-mail Address
same
Current Street Address
same
City
Fax Number N/A
State
Zip

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
Party is a Corporation, give name and street address of the Registered Agent:
N/A
Name of Registered Agent
Current Mailing Address
City State Zip
Telepho
E-mail Address
Current Street Address
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.
Mark Strickland
Type or print name
Signature�.L�
Nji1w' 641
Chief Facilities and Operations Officer
Title or Authority
Date
d1� a Notary Public of the County of
State of North Carolina, hereby certify that lkt,(k ��-(`( 604'. ud appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. 11
Witness my hand and notarial seal, this L' day of f , 20
Notary VV
Seal KATHERINE GRIFFIN TRAHAN
My commission expires NOTARY 211131 I(
Wake County
North Carolina
P,4y Commission Expires Aug. 31, 2022