NCC230823_FRO Submitted_20230327

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 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.
Project Name_ State Street Basin Water and Sewer Improvements Phase 2
Location of land -disturbing activity: County
Wake
City or Township Raleigh
State, Quarry, Coleman,
Highway/StreetDavy, Cumberland, Tipton, Latitude 35.770 Longitude-78.625
Trig awer, a . enoir, Beauty, Malta, erry roa , H CK Quarry}
3. Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.97 ac.
6. Amount of fee enclosed: $ 1600.00 . 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).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Todd Toler
Telephone [phone]
E-mail Address [e-mail]
Cell # NIA
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Raleigh (public road right-of-way)
Name
919-996-3070
Telephone
PO Box 590 222 W. Hargett Street
Current Mailing Address Current Street Address
N/A
Fax Number
Raleigh NC 27602 Raleigh NC 27602
City State Zip City State
Zip
10. Deed Book No. NIA Page No. NIA Provide a copy of the most current deed.
Part B.
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.
William Wheeler
Raleigh Water (Public Utilities) [e-mail]
Name E-mail Address
PO Box 590 222 W. Hargett Street
Current Mailing Address Current Street Address
Raleigh NC _ 27602 Raleigh NC 27602 _
City - State Zip City State Zip

Telephone [phone] Fax Number NIA
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 State
Telepho
E-mail Address
Current Street Address
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.
William WheeleV1 Department Director, Public Utilities
Tre pri n Title or Authority
2n2-7—
Signature Date
Sarah Weisenburn
a Notary Public of the County of
Johnston
State of North Carolina, hereby certify that William Wheeler appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness rUjmhO, t Em4_notarial seal, this
day of February , 20 22
'j.
Notary
My commission expires 7/29/24