NCC230307_FRO Submitted_20230207

NC Dept of Environmental Quality
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JUL 15 2022
SEDIMENTATION POLLUTION CONTROL ACT Raleigh Regional QtTico
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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Baucom Elementary Rebuild
2. Location of land -disturbing activity: County Wake City or Township Apex
Hunter Street-78.854189 35.737251
Highway/Street Latitude{a�;maie��g� Longitudeca���a��s�
3. Approximate date land -disturbing activity will commence: March 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Educational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.0 Acres
6. Amount of fee enclosed: $1 , 500.00 . 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 ❑ Enclosed ❑ No ❑x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brandon Williams E-mail Address [e-mail]
Phone: Office # 919.694.7553 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wake County Board of Education [phone]
Name Phone: Office # Mobile #
1551 Rock Quarry Rd 1551 Rock Quarry Rd
Current Mailing Address Current Street Address
Raleigh NC 27610 Raleigh NC 27610
City State Zip City State Zip
10. Deed Book No. 1 579 Page No.60 Provide a copy of the most current deed.
NC Dept off' vironmenW Quality
JUL 15 2022
Rgci& Regional Office

Part B.
I. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the companyis a sole proprietorship orifthe landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Wake County Board of Education
Company Name
111 Corning Road, Suite 190
Current Mailing Address
Cary, NC 27518
City State Zip
Phone: office # 919-588-3573
[e-mail]
E-mail Address
same
Current Street Address
same
City State
Mobile # n/a
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:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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:
NIA
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City
Mobile #
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.
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 Strickland
Type or print name
1 *1 vfp<
Signature
Chief Facilities and Operations Officer
Title or Authority
-7-o.'
Date
I, 0"04 (f(1�'ll & , a Notary Public of the County of
State of North Carolina, hereby certify that ka& %c 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 4ay of j�� , 20
kj
r
Notary
KATHERINE GRIFFIN TRAHAN
My commission expires _ _.. NoTABy el inn is
Waite County
North Carolina
My Commission Expires Aug. 31, 2022

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
NOT APPLICABLE
Name
Phone: Office #
Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
_ Provide a copy of the most current deed.
Landowner 3 of Record:
NOT APPLICABLE
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
NOT APPLICABLE
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
NOT APPLICABLE
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.