NCC230338_FRO Submitted_20230207

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Financial Responsibility/Ownership Form SPCA
See TOFV LDO, Section §9-1407 SOIL EROSION & SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
Part A.
1. Project Name_Berk-Tek Expansion
2. Location of land -disturbing activity: Highway/Street-100 Technology Park Lane
3. Approximate date land -disturbing activity will commence: _December 2022
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 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name_Karen Berry
T e l e p h o n e_919-552-2 061
E-mail [e-mail]
Cell #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
_Berk-Tek, LLC
Name
[e-mail]
E-mail Address
_132 White Oak Road _same as mailing address
Current Mailing Address Current Street Address
_New Holland, PA 17557
City State Zip
_same as mailing address
City State Zip
8. Deed Book No._015209 Page No._01962 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):
_MLG Construction [e-mail]
Name E-mail Address
_3301 Glen Royal Road _same as mailing address.
Current Mailing Address Current Street Address
_Raleigh, NC 27617 _same as mailing address,
City State Zip City State Zip
Telephone_919-977-1646
Town of Fuquay-Varina E 134 N Main Street, Fuquay-Varina, NC 27526
[phone] E fuquay-varina.org

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 Town of
Fuquay-Varina Land Development Ordinance and/or Land Disturbance Permit:
Name
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
City State Zip
Telephone
(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 Parry is a Corporation, give name
and street address of the Registered Agent:
_Lyle Gurley
Name
—[e-mail]
E-mail Address
_3301 Glen Royal Road _same as mailing address
Current Mailing Address Current Street Address
—Raleigh, NC 27617 _same as mailing address
City State Zip City State Zip
Telephone-9 19-977-1646
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.
i
Type or print na a itle or Authority
Sign re Date
----- —---------------------- ------------------------ ----------------------------------------
a Notary Public
" of the County of Q
1
State of North Carolina, hereby certify that S f� LLi _t26U eq appeared personally
before me this day and being duly sworn acknowledged that4he above for was executed by him.
Witness my hand and notarial seal, this day of TRINUai( 20 a3
MARGIE GURLEY Notary
NOTARY PUBLIC _ �3 a OAS Se I CHATHAM COUNTY, N.C. My commi Sion expires
20221201