HomeMy WebLinkAboutNCC221097_FRO Submitted_20220318WAKE 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
W� County Unified Development Ordinance before this form and an acceptable erosion and
OUNTY sedimentation control plan have been completed and approved by Wake County Department of
C
r�c,�nnt,i ��n 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 Greenfield 27 Flex and Industrial Park
2. Location of land -disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street Waterfield Drive Latitude 35.682159 Longitude -78.563375
3. Approximate date land -disturbing activity will commence: January 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Light Industrial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 21.0 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jimbo Dixon E-mail Address jimboCa�abgoodrich.com
Telephone 919-828-6609 ext. 122 Cell # 919-247-3817 Fax # 919-828-6698
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Greenfield 27 LLC 919-828-6609 agoodrich@abgoodrich.com
Name(s)
1001 College Ct
Current Mailing Address
New Bern, NC
City
State
8. Deed Book No. 018573
Part B.
Telephone Fax or E-mail address
1001 College Ct
Current Street Address
28562 New Bern, NC 28562
Zip City State Zip
Page No. 00541 Provide a copy of the most current deed.
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):
A.B. Goodrich Contracting, LLC agoodrich@abgoodrich.com
Name E-mail Address
629 Oberlin Rd
Current Mailing Address
629 Oberlin Rd
Current Street Address
Raleigh NC 27605 Raleigh NC 27605
City State Zip City State Zip
Telephone 919-828-6609
Fax Number 919-828-6698
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
Telephone
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State 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.
Type or print name Title or Authority
1, 11 JA_ I z !GL`&(
Signature Date
I, V a C- , a Notary Public of the County of VV C&Cq
State of North Carolina, hereby certify that A d r`I�-,fn appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of %PG_,b2(20�
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