NCC220172_MODIFICATION Supporting Doc (Updated FRO Contacts)_20230607

UPDATED 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Hilltop Needmore Road Elementary School (E-44)
2. Location of land -disturbing activity: County Wake City or Township Fuguay-Varina
4575 Hilltop Needmore Road 35.630115N-76.736993W
Highway/Street Latitude(decimal degrees) LOngitude(decimal degrees)
3. Approximate date land -disturbing activity will commence: Jul (ESP), January (Building)
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 23.24 Acres*
**
6. Amount of fee enclosed: $ 1,200+ . 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 ❑x No ❑
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 # 919.694.7533 Mobile # _ 919.422.1867
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wake County Board of Education 919.694.7542
Name Phone: Office # Mobile #
5625 Dillard Drive 5625 Dillard Drive
Current Mailing Address Current Street Address
Cary NC 27518 Cary NC 27518
City State Zip City State Zip
Town of Fuquay Varina [phone] n/a
Name Telephone Fax Number
401 Old Honeycutt Road _ _ Same
Current Mailing Address Current Street Address
Fuquay Varina NC 27526 Same
City State Zip City State Zip
10. Deed Book No. 2021 Page No. 01729 Provide a copy of the most current deed.
* Total disturbed acreage ac includes 11 acres previously approved as part of the Early Site Permit
(ESP), Permit Wake-2022-0172, 11.85 ac for the earlier submission and .39 ac for the additional path along
Hilltop Needmore Road.
**Fee is $1,300 for the 12 ac on the earlier revision + $100 for .39 ac this revision + ESP permit paid (11 AC x
$65 = $715) for a total fee of $2,015.

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 paq(ies).
Wake County Board of Education [e-mail]
Company Name
5625 Dillard Drive
E-mail Address
5625 Dillard Drive
Current Mailing Address Current Street Address
Cary NC 27518-9226 Cary NC
City State
Phone: Office # 919.694.7542
Zip City State
Mobile # [phone]
27518-9226
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:
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
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
f
Signature
Chief Facilities and Operations Officer
Title or Authority
Date
V� �� a Notary Public of the County of Wake
State of North Carolina, hereby certify that Mark Strickland 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 1�0 day of
Notary
Seal FKATHERINEiGR:IFFINPUBRAHAN
My commission allorth Cardinsion Expires August 312027

Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Name
Current Mailing Address
City
Deed Book No.!
Landowner 3 of Record:
Name
Current Mailing Address
City
Deed Book No._
.,...a.....- A of Den —A
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
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.
Name
Current Mailing Address
City
Deed Book No.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #