NCC221378_FRO Submitted_20220407

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
,\01,111 CARUI INA 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
2.
3.
Project NameShotwell C&D Landfill Material Recovery Facility
Location of land -disturbing activity: Jurisdiction Wake Co. (Wake Co. or Municipality)
Highway/Street 4724 Smithfield Rd Latitude 35.723616 Longitude -78.434128
Approximate date land -disturbing activity will commence: November 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): 3_96 Acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Josh Daher E-mail Address [e-mail]
Telephone [phone] Cell # 678-549-7874 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Shotwell Landfill Inc [phone]
Name(s) Telephone
103 Rupert Road 4724 Smithfield Road
Current Mailing Address Current Street Address
Raleigh NC
City State
8. Deed Book No. 008140
Part B.
27603 Wendell
Zip City
Page No. 00641
NC
State
[e-mail]
Fax or E-mail address
27591
Zip
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):
Shotwell Landfill Inc [e-mail]
Name E-mail Address
103 Rupert Road 4724 Smithfield Road
Current Mailing Address Current Street Address
Raleigh NC 27603 Raleigh NC 27614
City State Zip
Telephone [phone]
City
Fax Number
State
Zip

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip
City State Zip
Telephone
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:
Capitol Corporate Services, Inc.
Name of Registered Agent
E-mail Address
120 Penmarc Drive Suite 118
120 Penmarc Drive Suite 118
Current Mailing Address
Current Street Address
Raleigh NC 27603
Raleigh NC 27603
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.
Walter Hall, Jr
Chief Executive Officer
Type or print name Title or Authority
\1+-- I11 ��_aca1
Signature Date
a Notary Public of the County of
State of North arolina, hereby certify that V�i VV E C t� (x 1 \ , 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 N ti bV t 6_ 14
a.