NCC221959_FRO Submitted_20220525

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 Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name MTX One
2.
3.
4.
5.
Location of land -disturbing activity: County Wake
Highway/Street Social Street Latitude 35.8299
City or Township Raleigh
Approximate date land -disturbing activity will commence: 05/23/2022
Longitude-78.6234
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.5
6. Amount of fee enclosed: $ N/A . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes V No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Spenser Smith E-mail Address [e-mail]
Telephone [phone] Cell # 919.877.5975 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
St Albans Holdings LLC 919-863-1000
Name Telephone
3301 Benson Drive, Suite 103 3301 Benson Drive, Suite 103
Current Mailing Address Current Street Address
Fax Number
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
10. Deed Book No. 16847 Page No.
Part B.
1 •,
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):
St Albans Holdings LLC [e-mail]
Name E-mail Address
3301 Benson Drive, Suite 103
Current Mailing Address
3301 Benson Drive, Suite 103
Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
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:
Thomas Saieed, Jr
Name of Registered Agent
3301 Benson Drive Suite 103
Current Mailing Address
[e-mail]
E-mail Address
3301 Benson Drive, Suite 103
Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Telephone [phone]
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.
Thomas Saieed, Jr
Manager
Title or Authority
5/18/2022
Date
I, NO I iq MY 'P f a c JL , a Notary Public of the County of
State of North Carolina, hereby certify that 16MAT 5hjp'pj , :Iv-, appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and nota(«i ffl?I, this k daY of 20 2a
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