NCC223530_FRO Submitted_20221013

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__ Beech Bluff County Park
2.
3.
Location of land -disturbing activity: County V V ake
Highway/Street3355 NC Hwy 42 Latitude35.59 N
Approximate date land -disturbing activity will commence:Ap
ril
City or Township Panther Branch
Longitude 78.68 W
2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 37.1 Acres
6. Amount of fee enclosed: $ 2,470.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eric Staehle E-mail Address [e-mail]
Telephone [phone] cell # 919-830-0294 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wake County 919-856-5500 919-856-5504
Name Telephone Fax Number
PO Box 550 300 S. Salisbury St.
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27601
City State Zip City State Zip
10. Deed Book No. 01 7673 Page No.00603 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.
Wake County Facilities Design & Construction [e-mail]
Name
P.O. Box 550
Current Mailing Address
Raleigh, NC 27602
City
State Zip
Telephone [phone]
E-mail Address
336 S. Fayetteville Street, 11 th Floor
Current Street Address
Raleigh, NC 27601
City State
Fax Number 919-856-6355
Zip

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
Telephonie
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.
Mark Forestieri
Type or print name
Director, Facilities Design & Construction
Title or Authority
Signature Date
I, TI)4M4,5 Q V oort'`A. h a Notary Public of the County of r�rAnVl He
State of North Carolina, hereby certify that 1h ct r k T—o raS4 i e- T' t 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
♦���g1/111
0 �Mi00
#at A R r
%% Seal =
2 —day of NJvve►+l her , 20 Z-1
�Y -
Notary
My commission expires De4 ►",ey' 7-07-4