NCC231176_FRO Submitted_20230425

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 N/A in the blank.)
Part A.
1. Project Name Cleveland Fire Station #3
2. Location of land-disturbing activity: County Johnston City or Township Cleveland Township
Cornwallis Rd SR 1525 35.6131 -78.5350
Highway/Street Latitude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence:ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public Safety
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .90
6. Amount of fee enclosed 700 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brent Morris E-mail Address [e-mail]
Phone: Office# 919-868-1510 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Cleveland Fire Department, Incorporated 919-989-1909 N/A
Name Phone: Office# Mobile#
9039 Cleveland Road 9039 Cleveland Road
Current Mailing Address Current Street Address
Clayton, NC 27520 Clayton, NC 27520
City State Zip City State Zip
10. Deed Book No. 6256 Page No. 877-879 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).
Cleveland Fire Department, Incorporated [e-mail]
Company Name E-mail Address
9039 Cleveland Road 9039 Cleveland Road
Current Mailing Address Current Street Address
Clayton, NC 27520 Clayton, NC 27520
City State Zip City State Zip
Phone: Office# 919-989-1909 Mobile# [phone]
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:
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:
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)
(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

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:
Glen Ford, Jr and Stephanie Dean Ford N/A N/A
Name Phone: Office# Mobile#
5266 Cornwallis Road N/A
Current Mailing Address Current Street Address
Garner NC 27529 N/A
City State Zip City State Zip
Deed Book No. 5625 Page No. 69 Provide a copy of the most current deed.
Landowner 3 of Record:
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:
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:
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.

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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Adams & Hodge Engineering, PC [e-mail]
Engineering firm or other consultant E-mail Address
Amanda Grimm 513-325-3192 513-325-3192
Individual contact person (type or print) Phone: Office# Mobile#
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.
Chris Ellington Fire Chief
Type or print name Title or Authority
(:j4,4 0 3114/23
Signature Date
I, L41,AikA—
, a Notary Public of the County of
State of North Carolina, hereby certify that t�hs tS �1 L. IL- �� 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 U l day of ( _ , 20 0L')
.\ (
•�'`,�0$, ..,..,. 4,,, Notary
Seal NOT�f- TO 3 My commission expires I 1 (g )
PUBL1G -'
?�T0N COV`'.''.:
"4wu waM"�'�