NCC231500_FRO Submitted_20230516

ot!flif E ' WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
...--"""gr:-. . SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WAKE County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY l------
sedimentation control plan have been completed and approved by Wake County Department of
^,, %/Z ,1.,k 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 4001 Campbell Road
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Campbell Road Latitude 35.7275 Longitude -78.7436
3. Approximate date land-disturbing activity will commence: April 3, 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): woodland to pasture
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 4.0
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Ahmad Quqa [e-mail]
Name E-mail Address
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record(attach accompanied page to list additional owners)
Ahmad Quqa & Nada Wafa 919 525 7175
Name(s) Telephone Fax or E-mail address
4001 Campbell Road 4001 Campbell Road
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
City State Zip City State Zip
17912 1317
8. Deed Book No. Page No. 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):
Ahmad Quqa [e-mail]
Name E-mail Address
4001 Campbell Road 4001 Campbell Road
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
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:
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.
Ahmad Quqa Owner
Type or print name Title or Authority
i ature Date
I, M(MG- Cj . APIAt.r% , a Notary Public of the County of UJaJ( .
State of North Carolina, hereby certify that A r1 /0 () Ik.€C. appeared
personally before me this day and being duly s rn acknowledged that the above foam was executed by him.
Witness my hand and notarial seal, this ii day of OrI ) , 20 e 3
MONA 5 AMIRI . 4ea'-r\----- • -bOtary
I Notary Pubitc yMorth Carolina I
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