NCC224216_FRO Submitted_20230119

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.
Project Name Ralei h Bivd Trail Realignment and Relocation Project
2. Location of land -disturbing activity: County Wake City or Township_ Raleigh
Highway/Street 1000 & 1600 Crabtree Blvd; 1600 Marlborough Rd; Raleigh, NC 27602
Latitude 35.8041 Longitude-78.606
3. Approximate date land -disturbing activity will commence: September 202
4. Purpose of development (residential, commercial, industrial, institutional, etc.): greenway relocation
and realignment, streambank stabilization
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.21
6_ Amount of fee enclosed: $ 800 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
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:
M
Name David Bender E-mail Address david.bender@ralei, hchnnc.gov
Telephone_(919)996-4708 Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
City of Raleigh NIA
Name Telephone
PO Box 590 222 Hargett St
Current Mailing Address Current Street Address
NIA
Fax Number
Raleigh NC 27602-0590 Raleigh NC 27601
City State Zip City State Zip
10. Deed Book No. 002694 Page No. 00211 Provide a copy of the most current deed.
Deed Book No. 002689 Page No. 00542 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
City of Raleigh [e-mail]
Company Name
222 West Hargett Street
Current Mailing Address
Raleigh, NC 27601
City State
Phone: Office # 919-996-4784
E-mail Address
222 West Hargett Street
Current Street Address
Raleigh, NC 27601
Zip City
Mobile #
State
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As, If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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 individuals)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
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I,�Vnnl�___1��,_�}rr�5 a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowl dged that the abov orm was executed by him/her.
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