NCC230680_FRO Submitted_20230315

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Celeste Circle Forcemain
2. Location of land -disturbing activity: County Durham City or Township Durham
Highway/Street NC Hwy 54 Latitude 35.9103440 Longitude-78.986937'
3. Approximate date land -disturbing activity will commence: March 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.85± Acres
6. Amount of fee enclosed: $ 325.00. 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 Lisa Mitchell E-mail Address [e-mail]
Telephone [phone], x 35568 Cell # 919-943-9722 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Durham
Name
101 City Hall Plaza
Current Mailing Address
Durham NC 27701
City State Zip
919-560-1200 919-560-4479
Telephone Fax Number
Same as Mailing Address
Current Street Address
City
State
Zip
10. Deed Book No. 334 Page No. 693 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.
City of Durham — Department of Water Management Don.Greeley65�DurhamnC.gOv
Name E-mail Address
1600 Mist Lake Drive Same as mailinq address
Current Mailing Address Current Street Address
Durham, NC 27704
City State Zip City State Zip

Telephone [phone] Fax Number 919-560-4479
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:
NIA
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:
NIA
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.
Donald F. Greeley, PE Director, City of Durham Water Management
Type or print name Title or Authority
/ e�i z fzl
Signature Date
--------------------------------- --------------------------------------------------------------------------------------------------
CI, a Notary Public of the County of
State of North Carolina, hereby certify that AILIL64 appeared
personally before me this day and being duly sworn acknowledged t at the abo farm was executed by
him.
Witness my hand and notarial seal, this /^day of , 20
Ua� a -
CAROL A PiCKETT Notary
Notftfublic, North Carolina
Durham County My commission expires a�
My C mis ion Expires