NCC223413_FRO Submitted_20221011

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land -disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH C;AROLINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name Duke Health - Garner Medical Office Building
2. Location of land -disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street Timber Drive Latitude 35.685218 Longitude -78.601294
3. Approximate date land -disturbing activity will commence: July 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 18.5 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Stout E-mail Address [e-mail]
Telephone [phone] Cell # 919-930-5218 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke University Health System Inc.
Name(s) Telephone Fax or E-mail address
310 Blackwell Street, FL 4 310 Blackwell Street, FL 4
Current Mailing Address Current Street Address
Durham, NC 27701 Durham, NC 27701
City State Zip City State Zip
8. Deed Book No. 018406 Page No. 01744 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Duke University Health System Inc. Kevin. [e-mail]
Name E-mail Address
310 Blackwell Street, FL 4
Current Mailing Address Current Street Address
Durham, NC 27701
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
t 1 C'ti i r1 Lou ��U^
Name
S`i2 6 f a')j Ge'1i4 Ag6 n
Current Mailing Address
Aotp r NC U500.
City State Zip
Telephone cf! 9- y1N- 1301
��t . �� �� e- O."he. ed"I
E-mail Address
Current Street Address
City
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.,
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip 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.
C eUin A
Type or print name
�'A A AM bl��'
Signature
Title or Authority
Date
5 1v.-a'j-
I, JAk, a Notary Public of the County of
State of Nort Carolina, hereby certify that Vl appeared
personally before me this day and being duly sworn acknowledged that t e bove form was executed by him.
Witness my hand and notarial seal, this u' " 'day of20✓-