NCC222958_FRO Submitted_20220818

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 N/A in the blank.)
Part A. 1. Project Name Knightdale Fire Station #4
2
3
4
5
6
Location of land -disturbing activity: CountyWake City or Township Knightdale
Highway/street Hodge Road Latitude35.787870 Longitude-78.523564
Approximate date land -disturbing activity will commence: September 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Public/Institutional
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.4 acres
Amount of fee enclosed: $ 500 . 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Phillip Bunton E-mail Address [e-mail]
Telephone [phone] Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Knightdale 919-217-2294
Name
950 Steeple Square Court
Current Mailing Address
Knightdale, NC 27545
City
10. Deed Book No.
State Zip
2022 Page No.
Telephone Fax Number
950 Steeple Square Court
Current Street Address
Knightdale, NC 27545
City
871
State
Zip
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.
Town of Knightdale [e-mail]
Name E-mail Address
950 Steeple Square Court
Current Mailing Address
Knightdale, NC 27545
City State Zip
Telephone [phone]
950 Steeple Square Court
Current Street Address
Knightdale, NC 27545
City State Zip
Fax Number N/A

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State 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
Current Mailing Address
City
Telephone_
E-mail Address
Current Street Address
State Zip City State Zip
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.
Jessica Day Mayor
Type or print name Title or Authority
Sig6ture Date
M Si-nr , a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of �, , u , 20SOO
07
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aR:2.
• NOT Notary
Seal Y = _
In )'UEXIC My commission expires j ur)e-
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KNIGHTQALE
u�ilir.• works
July 22, 2022
HUERTA, ARNOLDO HUERTA, MARIA G
721 S NEW HOPE RD STE 104
RALEIGH NC 27610-7915
Town of Knightdale 950 Steeple Square Ct. Knightdale, NC 27545
KnightdaleNC.gov ! 919-217-2250
RE: Fire Station #4 Construction Easement
Town of Knightdale
950 Steeple Square Ct
Raleigh NC 27545
County of Wake
To Whom it May Concern:
This letter gives Town of Knightdale authority to pursue plan approvals for erosion and
sediment control plans for the Hodge Road Fire Station #4, located at 1325 Hodge Rd,
Knightdale NC 27545. We also give permission for Town of Knightdale to perform construction
activities on this property within ROW Boundaries of the lots identified as PIN 1744127151, and
1744123290.
Please contact me with any questions,
Sincerely,
HUERTA, ARNOLDO HUERTA, MARIA G
Landowner