NCC221335_FRO Submitted_20220406

O-W WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=7 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
NOR IH (ARo„NA 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 GNICBuildinq Expansion
2. Location of land -disturbing activity: Jurisdiction Zebulon
(Wake Co. or Municipality)
Highway/Street E Gannon Ave Latitude 35,827 Longitude-78.307
(NC Hwy 97)
3. Approximate date land -disturbing activity will commence: N m r 15 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 8.10 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Linda Arnold
Telephone [phone] Cell # [phone] Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
TEB 0, LLC [phone] _ [e-mail]
Name(s) Telephone Fax or E-mail address
10729 Tre o Trail 1300 Chatsworth Ln
Current Mailing Address Current Street Address
Raleigh NC 27614 Raleigh NC 27614
City State Zip City State Zip
8. Deed Book No. 16455
Part B.
Page No. 2641
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):
TEB 0, LLC
Name
10729 Trego Trail
Current Mailing Address
Raleigh
City
[e-mail]
E-mail Address
1300 Chatsworth Ln
Current Street Address
NC 27614 Raleigh NC 27614
State Zip City State
Telephone [phone] Fax Number
ZJp

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:
N/A
Name
Current Mailing Address
City
Telephone,
E-mail Address
Current Street Address
State 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:
N/A
Name of Registered Agent
Current Mailing Address
City
State Zip
E-mail Address
Current Street Address
City
Telephone Fax Number
State Zip
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.
Mark Andrews
Type or pLrsnt nagne
Signature
d►d!j1'y-
Title or Autho ity
-� I -�' 7'o
Date k
a Notary Public of the County of
State of North Carolina, hereby certify that TJ 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 5� 1 day of _MaYC1 20 a�
' LISA L. MARKEY
E Notary Public, North Carolina.
Wake County Notary
My Commission Expires
June 25, 2023 My commission expires QUU02 02�02 3