HomeMy WebLinkAboutNCC230146_FRO Submitted_20230119Check if this project is ARPA-funded ❑
FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NCG01 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 Jordan Lake Water Reclamation and Reuse Project -Phase 2 RTP South
*lf this project involves American Rescue Plan Act (ANPA) funds, list the Project Name oelow
under which you applied for funding through the Division of Water Infrastructure (DWI).
N/A
2. Location of land -disturbing activity: County Wake City or Township Cedar Fork
Varies 35.857178-78.888245
Highway/Street _ Latltude(decimaldegrew) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: January 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Reclaimed Water
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.17
Paid $715.00 Previously
6. Amount of fee enclosed: $ _ _. 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 ❑x Enclosed ❑ No ❑
91
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Matt Mlles E-mail Address matt miles@aecom.com
aecom.Com
Phone: Office # 919-337-6460 Mobile # 919-337-6460
9. Landowner(s) of Record (attach accompanied page to list additional owners):
North Carolina Department of Transportation 919-707-4361
Name
1546 Mail Service Center
Current Mailing Address
Raleigh NC 27699-1546
Phone: Office #
1 S. Wilmington St.
Current Street Address
Raleigh NC
919-733-1390
Mobile #
27601
City State Zip City State /_ip
10. Deed Book No. On Drawings Page No. On Drawings Provide a copy of the most current deed.
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).
Wake County Facilities Design & Construction
Company Name
P.O. Box 550
Current Mailing Address
Raleigh NC
City State
Phone: office # 919-856-6350
27602
Zip
mark.forestieri@wakegov.com
E-mail Address
336 Fayetteville Street, WCOB, 11 th floor
Current Street Address
Raleigh NC
City State
Mobile # 919-856-6355
27601
Zip
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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
%a[Ly
Phone: Office # N/A
N/A
State Zip
0P.,
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Mobile # N/A
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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City
Phone: Office # N/A
N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
State Zip City
Mobile # N/A
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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.
N/A
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.
Mark Forestieri
Type or print name
Signature
Facilities Design & Construction Director
Title or Authority
1-17- z=-z3
Date
I, -Z TmCIMAAH t'Symti , a Notary Public of the County of _ jk-Y-� .-
State of North Carolina, hereby certify that pdo t14- appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this _ day of jphj,- 'ti , 20
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