NCC221145_FRO Submitted_20220413

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. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place NIA in the blank.)
Part A. Varsity Drive Parking Lot Expansion
1. Project Name
2. Location of land -disturbing activity: CountyWahe City or Township Raleigh
Highway/StreetVarsity Drive Latitude35.780936 Longitude-78•685109
3. Approximate date land -disturbing activity will commence:6.1.22
4. Purpose of development (residential, commercial, industrial, institutional, etc,): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.7
6. Amount of fee enclosed: $ 700.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lynn Swank E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
North Carolina State University 919-515-2155 919-515-7121
Name
Telephone Fax Number
Campus Box 7201
20 Watauga Club Drive - B Holladay Hall
Current Mailing Address
Current Street Address
Raleigh NC 27695-7201
Raleigh NC 27695
City State Zip
City State Zip
10. Deed Book No. 95 Page No.246 Provide a copy of the most current deed.
Part B.
1. Company(les) 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 companyorfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Charles A. Maimone - NC State University
camaimonCZ-bncsu.edu
Name
E-mail Address
Campus Box 7201
20 Watauga Club Drive - B Holladay Hall
Current Mailing Address
Current Street Address
Raleigh NC 27695-7201
Raleigh NC 27695
City State Zip
City State Zip
Telephone[phone]
Fax Number919-515-5121
Doc ID: 506aef5gdb32bd417a95c4db5908146dl33led33

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
Telephone
State Zip City
Fax Number
State Zip
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.
aD--eit", .4, �l�Mr� VOL ChMO-I109r
Typ or print name Title or Authority
4
Signature Date
I� �u Wave
a Notary Public of the County of V�
State of North Carolina, hereby certify that e'hac appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. 1,,�,
Witness my hand and notarial seal, this 44 day of 30A� L , 20 2 2"
MAROTARY PUB AC IS
N COUNTY, No,
WA1� ,
{V1y ComrnIS5;0113-11.2023.
O1CLq �- f'..C-L-�a tits
Notary
My commission expires 3 ` 1 E -903
Doc ID:506ae#59db32bd417a95a4db59o8146dl33led33