NCC216293_FRO Submitted_20211123

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land -disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NOMFt C:AR01INA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1.
Project Name Islamic Association of Raleigh Cemetery
2.
Location of land -disturbing activity:
Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Hankinson Road
Latitude 35.841121673583984 Longitude-78.40476989746094
3.
Approximate date land -disturbing activity will commence: 09/15/21
4.
Type of development (residential, commercial, industrial, institutional, etc.): Institutional
5.
Total acreage disturbed or
uncovered (including off -site utilities and borrow/waste
areas): 6.043 acres
6.
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Imran Aukhil
E-mail Address [e-mail]
Telephone
Cell # 919-931-7106 Fax #
7.
Landowner(s) of Record (attach accompanied page to list additional owners):
Islamic Association of Raleigh
919-834-9572
Name(s)
Telephone Fax or E-mail address
808 Atwater Street
808 Atwater Street
Current Mailing Address
Current Street Address
Raleigh NC
27607 Raleigh NC 27607
City State
Zip City State Zip
8.
Deed Book No. 010231
Page No. 669-671 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):
Islamic Association of Raleigh
[e-mail]
Name
E-mail Address
808 Atwater Street
808 Atwater Street
Current Mailing Address
Current Street Address
Raleigh NC
27607 Raleigh NC 27607
City State
Telephone [phone]
Zip City
Fax Number
State
Zip

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
Current Mailing Address
City State
Telephone.
E-mail Address
Current Street Address
Zip City State Zip
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.
Danyal Khan CEO
Type or p14 name Title or Authority
/ 17>� 01.103 Iz'
Si nat Date
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46
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-,a Notary Public of the County of l�/tIC_�
State of North Carolina, hereby certify that /t/21 /� �P appeared
personally before me this day and being duly sworn acknowle gLLed that the above form was executed by him.
Witness m,j�iot1�1' dig9tarial seal, this f��day of TeDT�kV , 20� 1
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