NCC223462_FRO Submitted_20221006

EW-0 WAKE COUNTY 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 Wake
WAKE
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH CARD LINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name Wendell Commercial
2. Location of land -disturbing activity: JurisdictionTown of Wendell / Wake County(Wake Co. or Municipality)
Highway/Street NC HWY 64 Latitude 35d47'30" N Longitude-78d22'39" W
3. Approximate date land -disturbing activity will commence: April, 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 2.40 Ac.
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jason Swain
E-mail Address jason(cD_swainassociates. com
Telephone [phone] Cell # n/a Fax # n/a
7. Landowner(s) of Record (attach accompanied page to list additional owners):
TCB Wrightsboro, LLC
910-256-2211
Name(s)
Telephone Fax or E-mail address
1131-B Military Cutoff Road
1131-B Military Cutoff Road
Current Mailing Address
Current Street Address
Wilmington, NC 28405
Wilmington, NC 28405
City State Zip
City State Zip
8. Deed Book No. 18455 Page No.
1615-1621 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
TCB Wrightsboro, LLC
[e-mail]
Name
E-mail Address
1131-B Military Cutoff Road
1131-B Military Cutoff Road
Current Mailing Address
Current Street Address
Wilmington, NC 28405
Wilmington, NC 28405
City State Zip
City State Zip
Telephone [phone]
Fax Number n/a

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name
Current Mailing Address
City State
Telephon
E-mail Address
Current Street Address
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:
Jason Swain
Name of Registered Agent
1131-B Military Cutoff Road
Current Mailing Address
Wilmington, NC 28405
[e-mail]
E-mail Address
1131-B Military Cutoff Road
Current Street Address
Wilmington, NC 28405
City State Zip City State Zip
Telephone [phone] Fax Number n/a
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.
t name Title or A thority
Dam
I, r ti,(!, 1► , &A:!5 , a Notary Public of the County of NAA, V I/MN--ey
State of North Carolina, hereby certify that &iVVV V• 5W4 it appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and
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