NCC242250_FRO Submitted_20240724

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Spottswood Street Stormwater Control Measure Retrofit&Durant Nature Preserve Stream Restoration
`If this project involves American Rescue Plan Act (ARPA) funds. list the Project Name below
under which yotr applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Wake City or Township Raleigh
Spottswood St. 35.88885 -78.58270
Highway/Street Latltude(decimaldegrees) LongltUde(decimaldegrees)
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.2 Acres
6. Amount of fee enclosed: $300.00 . 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❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Amy Farinelli E-mail Address [e-mail]
Phone: Office# 919-996-4008 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Raleigh [phone]
Name Phone: Office# Mobile#
1 Exchange Plaza,7th floor,Rm.706,Attn:Amy Farinelli 222 W. Hargett Street
Current Mailing Address Current Street Address
Raleigh NC 27601 Raleigh NC 27601
City State Zip City State Zip
10. Deed Book No. 5741 Page No.364 Provide a copy of the most current deed.
18447 Page No. 2470

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 E-mail Address
P.O. Box 590 222 W. Hargett Street
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27601
City State Zip City State Zip
Phone: Office# 919-996-5575 Mobile#
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:
Marchell Adams-David
Name of Registered Agent E-mail Address
P.O. Box 590 222 W. Hargett Street
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27601
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 individual(s)
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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State of North Carolina, hereby certify that�1 C r� appeared personally
before me this day and being duly sworn acknowledged that the above form ulas executed by him/her.
Witness my hand and notarial seal, this ✓" day of -11 t L , 20 p'Z3
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
RDU Lincoln Park North Property Owner LP
Name Phone: Office# Mobile#
3843 West Chester Pike
Current Mailing Address Current Street Address
Newtown Square, PA 19073
City State Zip City State Zip
Deed Book No. 18447 Page No.2470 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

i

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: 1727399804
STREET ADDRESS: 8305 CAMP nURANT ROAn RAI FIGK NC 27615
Please print: CITY OF RALEIGH (ATTN: RICHARD KELLY)Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
RONALD JOHNSON , of AECOM
(Contractor/Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
P.O. BOX 590, RALEIGH, NC 27602
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature Aut orized Signa
Date: Date: 7/Q'�L3