NCC232074_FRO Submitted_20230719

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. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project NameWest Neuse and Crabtree Creek Interceptor Rehabilitations
2. Location of land-disturbing activity: CountyWake City or Township Raleigh
Highway/Street Linear Project Latitude35.8512 Longitude-78.5299
3. Approximate date land-disturbing activity will commence:January 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Municipal Utility (Sewer)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):37
6. Amount of fee enclosed: $2,405 . 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 Robert Massengill E-mail Address [e-mail]
Telephone[phone] Cell# N/A Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Raleigh Water 919.996.3490 N/A
Name Telephone Fax Number
P.O. Box 590 One Exchange Plaza - Suite 620
Current Mailing Address Current Street Address
Raleigh NC 27602-0590 See Attached sheet for additional property owners
City State Zip City State Zip
10. Deed Book No.N/A-linear project Page No.N/A-linear project 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 Raleigh [e-mail]
Name E-mail Address
222 Hargett St., Suite 224 222 Hargett St., Suite 224
Current Mailing Address Current Street Address
Raleigh NC 27601 Raleigh NC 27601
City State Zip City State Zip
Telephone [phone] Fax Number

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 Director - Raleigh Water
Type or print name . Title or Authority
„7" G •ZY-Zo
Signature Date
I,Coa f cfl2 -T , a Notary Public of the County of V Va 6e-
State of North Carolina, hereby certify that (3 "1- L. 11 Wd I 1 appeared
personally before me this day and being duly sworn acknowledged tl t the above form was
executed by him. JUN-
Witness my hand and notarial seal, this 1 day of , 20 2.0
I1! ;:
ob otary
My commission expires J Z 114p 122,