NCC230477_FRO Submitted_20230217

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. South Main Street Improvements and Burlington Mills Road Realignment (U-6241)
1. Project Name
2. Location of land -disturbing activity: County Wake
City or Township Rolesville
Highway/Street
SM�Latitude Longitude �StB&M91o�MV$Rd,WyWrgStitis40� 35.92384°-78.456730
3. Approximate date land -disturbing activity will commence: February 2022
4, Purpose of development (residential, commercial, industrial, institutional, etc.): Transportation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 37.9
6. Amount of fee enclosed: $ 2470 . 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 X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kelly Arnold E-mail Address [e-mail]
Telephone [phone] Cell #
Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
State of North Carolina
Name
Current Mailing Address
Telephone
Current Street Address
Fax Number
City State Zip City State Zip
10. Deed Book No. N/A Page No. N/A 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 Rolesville
P.O. Box 250
Current Mailing Address
Rolesville, NC 27571
City
[e-mail]
E-mail Address
502 Southtown Circle
Current Street Address
Rolesville, NC 27571
State Zip City
Telephone [phone]
State
Fax Number 919.556.6852
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 E-mail Address
Current Mailing Address
City
Current Street Address
State Zip City
Telephone Fax Numbe
State Zip
(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 State Zip City State Zip
Telephone 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
correctedl'nformation should there be any change in theeiinformation provided herein.
4 A,�,,d(J
- 1. �!� AL_��
Type or priAt name/ Title or Authority
Si re Date
------------------------------------------------ ------------------------------------------- --------- ------------------------- ----
I, a Notary Public of the County of Lez1Ae_
State of North Carolina, hereby certify that &1)04appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness(A ,r d•n (trial seal, this !Y day of Aea&20 �
C3
Notary
- tjoy?;,.�' Seal -
My commission expires
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