NCC222073_FRO Submitted_20220603

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
T 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
NORTH CAROLINA 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_ Morrisville Parkway Mixed Use
2. Location of land -disturbing activity: Jurisdiction Morrisville (Wake Co. or Municipality)
Highway/Street Morrisville Parkway Latitude 35°48'33.08"N Longitude 78°49'8.06"W
3. Approximate date land -disturbing activity will commence: August 15, 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Mixed -Use
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 7.61 ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jael Wagoner E-mail Address [e-mail]
Telephone [phone] Cell # 919.274.9288 Fax # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
PBR Subsidiary, LLC c/o CASTO Southeast
Realty Services _919.467.8880 919.518.9268
Name(s) Telephone Fax or E-mail address
215 E. Chatham St., Suite 201 250 Civic Center Drive, Suite 500
Current Mailing Address Current Street Address
Cary NC 27511 Columbus OH 43215-5088
City State Zip City State Zip
8. Deed Book No. 016353 Page No. 02355 Provide a copy of the most current deed.
5 01653
Part B. 016272 00525
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):
PBR Subsidiary, LLC c/o CASTO Southeast
Realty Services [e-mail]
Name E-mail Address
215 E. Chatham St., Suite 201 250 Civic Center Drive, Suite 500
Current Mailing Address Current Street Address
Cary NC 27511 Columbus OH 43215-5088
City State Zip City State Zip
Telephone [phone] Fax Number 919.518.9268

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:
Thomas Lowell [e-mail]
Name
215 E. Chatham St., Suite 201
Current Mailing Address
Cary
City
Telephone [phone]
NC 27511
State Zip
E-mail Address
215 E. Chatham St., Suite 201
Current Street Address
Cary NC 27511
City State Zip
Fax Number 919.518.9268
(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 attomey-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 I II I f Vice President
Type
Signature
Title or Authority
06/01/2022
Date
I, t��W kS , a Notary Public of the County of
State of North Carolina, hereby certify that jo nud S 1, we appeared
personally before me this day and being duly swom acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this I day of -1-41rl'e 20 22
�� otary
Seal = N p T A R Y
My commission expires 2�2_5
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