NCC223623_FRO Submitted_20221021

lx�w. WAKE 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
WAKECounty 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
COCO
cnaoLiNn Environmental Services, Water Quality Division. (Please type or print and, if the question is not
NORTH
applicable, place N/A in the blank.)
Part A.
1. Project Name Rolesville Dental Office
2. Location of land -disturbing activity: Jurisdiction Town of Rolesville (Wake Co. or Municipality)
Highway/Street S Main Street Latitude 35.909154 Longitude-78.478559
3. Approximate date land -disturbing activity will commence: 10/1 /2022
4. Type of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1.46 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ally Justmann E-mail Address [e-mail]
Telephone [phone] Cell #
Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Hampton Pointe Associates LLC
L
Name(s)
1207 Roseneath Rd, STE 200
Current Mailing Address
Richmond, VA 23230
Telephone
same
Current Street Address
City State Zip City
Deed Book No. 010051 Page No. 00530-00533
State
Fax or E-mail address
Zip
Provide a copy of the most current deed.
Part B.
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):
WMG Development, LLC [e-mail]
Name E-mail Address
PO Box 768 same
Current Mailing Address Current Street Address
Effingham, IL 62401
City State Zip City State Zip
Telephone [phone] Fax Number

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:
Toby Coleman [e-mail]
Name E-mail Address
150 Fayetteville Street, Suite 2300
Current Mailing Address Current Street Address
Raleigh, NC 27601
City State Zip City State Zip
Telephone [phone] 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:
Jonathan Brumleve [e-mail]
Name of Registered Agent E-mail Address
PO Box 768
Current Mailing Address Current Street Address
Effingham IL 62401
City State Zip City
Telephone [phone]
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.
Jonathan Brumleve Manager
Type or print ame
Signature
Title or Authority
N Z07-7-
Date
1, FArik, a Notary Public of the County ofn' / -AGUM]
State of 4l , hereby certify that c ILYN _ 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 Olt day of , 20 2
OFQFjIICIAL SEAL Notary
CHER
NOTAR P��C1C, STATE OF ILLINOIS
MY COMMISSION EXPIRES 10/29/2025 My commission expires