NCC223727_FRO Submitted_20221102

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 NIA in the blank.)
Part A. West Neuse Interceptor Improvements
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Raleigh
Highway/Street Crosses 1-87 & Us-64 BUS Latitude 78 deg 32'24.229"W Longitude 35 deg 46'5.153"N
3. Approximate date land -disturbing activity will commence: November 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 75
6. Amount of fee enclosed: $ 4,875.00 . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Janeen Goodwin E-mail [e-mail]
Telephone [phone] Cell # 919-360-6826 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached table
Name
Telephone Fax Number
Current Street Address
Current Mailing Address
City State
Zip City State Zip
10. Deed Book 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 maybe listed as the financially responsible party.
City of Raleigh
[e-mail]
Name
E-mail Address
PO Box 590
One Exchange Plaza, SuitaZZQ
Current Street Address
Current Mailing Address
Raleigh NC
27602 Raleigh NCs`: '' 4=,'27601
City State
Zip City State sZip
Telephone [phone]
Fax Number ;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:
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:
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.
Robert Massengill
Type or print name
Z-0- 4 � Z- � �- � �/ .' �Z'
Signature 1/7
Director - Raleigh Water
Title or Authority 6�p
Date
I, &12� 12 . ItA , , a Notary Public of the County of f '
State of North Carolina, hereby certify that 6A& M6K ill appeared
personally before me this day and being duly sworn acknowle ged that the above form was
executed by him.
Witness my hand and notarial seal, this 'T6 day of A6&V 20_
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�OIA�). Ofi Notary
c�oMr aMAes My commission expires_ ! -0 21
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