NCC240997_FRO Submitted_20240405

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 Environment and Natural Resources. (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 Name: Wake BRT New Bern Ave
2. Location of land-disturbing activity: County: Wake City or Township: Raleigh
Highway/Street: New Bern Ave Latitude: 35.779803 Longitude: 78.618978
3. Approximate date land-disturbing activity will commence: June 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Transportation
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 64 Ac.
6. Amount of fee enclosed: $ 6400. The application fee of$100.00 per acre (rounded up to the next acre) is assessed
without a ceiling amount (Example: a 9-acre application fee is $900).
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: Sam Brewer, P.E. E-mail Address: [e-mail]
Telephone: [phone] Cell#(same) Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
See list attached.
10. Deed Book No.: See list attached.
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): Please see page 3 attached.
City of Raleigh [e-mail]
Name E-mail Address
PO Box 590 222 W Hargett St.
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27601
City State Zip City State Zip
Telephone: [phone] Fax Number:
9

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:
Marchell Adams-David -City Manager [e-mail]
Name of Registered Agent E-mail Address
PO Box 590 222 W Hargett St
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27601
City State Zip City State Zip
Telephone: [phone] Fax Number: N/A
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.
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Signature Date
I, nv es 3, LOAD t 1`- , a Notary Public of the County of t1)04`-G
State of North Carolina, hereby certify that l\ C)IIWAC\ Kde.0 L. appeared personally before me this
day and being duly sworn acknowledged that the above form was executed byhim.
Witness my hand and notarial seal, this 2L day of Lk , 20 ,Z,�J
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