NCC231612_FRO Submitted_20230526

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
Countyseientati Unifiedn Development
controlplanhave Ordbeinance bob
COUNTY dmoen completedefore and this approvedfrm byand an Wake Countyaccepta le Depart erosionment ofand
N<»FH �k, 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 Thompson Business Park
2. Location of land-disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street W Garner Road Latitude 35.721003 Longitude -78.624136
3. Approximate date land-disturbing activity will commence: Fall 2020
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial / Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 17.0
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ronnie Thompson E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
1529 Properties, LLC 919-722-9190
Name(s) Telephone Fax or E-mail address
1529 W Garner Road 1529 W Garner Road
Current Mailing Address Current Street Address
Garner,NC 27529 Garner,NC 27529
City State Zip City State Zip
8. Deed Book No. 11076 Page No. 971 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):
1529 Properties, LLC _ [e-mail]
Name E-mail Address
1529 W Garner Road 1529 W Garner Road
Current Mailing Address Current Street Address
Garner,NC 27529 Garner,NC 27529
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:
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:
Ronnie Thompson [e-mail]
Name of Registered Agent E-mail Address
1529 W Garner Road 1529 W Garner Road
Current Mailing Address Current Street Address
Garner,NC 27529 Garner,NC 27529
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.
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Type or print name Title or Authority
}R .44. Q ► 11- r ?- 2020
Signature Date
I, \ MA3 w\. VJ LS A- 1 , a Notary Public of the County of W A\L C.
State of North Carolina, hereby certify that Q-O'nh1 t • ZMorlAtSO," 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 Z7 day of IV\N , 20 20
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