NCC241040_FRO Submitted_20240408

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the 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
v , �� „ h 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 WAKE COUNTY VETERANS AFFAIRS OUTPATIENT CLINIC OFFSITE ROADWAY IMPROVEMENTS
2. Location of land-disturbing activity: Jurisdiction GARNER (Wake Co. or Municipality)
Highway/Street 2700 BENSON RD Latitude 35°39'19.51"N Longitude 78°36'53.37'W
3. Approximate date land-disturbing activity will commence: 04/01/2022
4. Type of development(residential, commercial, industrial, institutional, etc.):COMMERCIAL
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3.57
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name JASON RANEY, PE E-mailAddress [e-mail]
Telephone [phone] Cell# 828-455-2134 Fax# [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
900 RAND ROAD LLC 828-430-8676 828-437-4378
Name(s) Telephone Fax or E-mail address
100 N CITY PKWY STE 140 100 N CITY PKWY STE 140
Current Mailing Address Current Street Address
LAS VEGAS NV 89106-4613 LAS VEGAS NV 89106-4613
City State Zip City State Zip
8. Deed Book No. 019184 Page No. 01045 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):
900 RAND ROAD LLC [e-mail]
Name E-mail Address
100 N. CITY PARKWAY, SUITE 1520 100 N. CITY PARKWAY, SUITE 1520
Current Mailing Address Current Street Address
LAS VEGAS NV 89016-4613 LAS VEGAS NV 89106-4613
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:
FRED SMITH COMPANY
Name E-mail Address
6105 CHAPEL HILL RD 6105 CHAPEL HILL ROAD
Current Mailing Address Current Street Address
RALEIGH NC 27607 RALEIGH NC 27607
City State Zip City State Zip
Telephone [phone] 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 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
corrected information should there be any change in the information provided herein.
A4 el-7rI1e . C ,JVOLLy Au-T3f0 5/ 7L
Type or pri t name Title or Authority
(—S'414
Z//9/23
Signa re Date
I, ,(9rrtPJ bar , a Notary Public of the County of NOD (---
Gev /tot,
State of hereby certify that Yk7 $,tG/t) eONNVui/ appeared
personally before me this day and being duly sworn acknowledged that the above f m was executed by him.
Witness my hand and notarial seal,this 18day of OZ.
S�� issio� �'' Notary
Seal itp
. ,� m: = My commission expires Ally-• 0216/ p2Bd
cE.=: � NOTARY :<:
s to; pL1BOO ?0
Cr .