NCC232705_FRO Submitted_20230911

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
O WITH LANDOWNER CONSENT FORM
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No person may initiate any land-disturbing activity covered by the Durham City-County Unified Development Ordinance before a
Land Disturbing Permit is issued by the Sedimentation and Erosion Control Office.Issuance of a Land Disturbing Permit does not
relieve the permittee of the obligation to obtain any other licenses, permits and approvals as may be required by Federal, State,
County or Municipal governments. This office must be notified in writing of any change to the information on this form.
PLEASE TYPE OR PRINT
1. Project name:RDU - CNG Fueling Station Extension: Yes or No
2. Road location of land-disturbing activity: 1110 Stone Rd / 1212 Stone Rd, Durham, NC 27703
Tax Map-Block-Parcel: 202369, 202368 PIN: 0840-30-67-9841, 0840-30-36-4718
3. Square footage of land to be disturbed or uncovered:261,360 SF
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
Cherokee Borden Properties LLC
Name
2825 Lakeview Dr
Address
Raleigh NC 27609
City State Zip
Telephone Fax Email
5. List the person or entity financially responsible for this land-disturbing activity: The financially responsible party shall
be (1) the developer or other person who has or holds themselves as having financial or operational control over the land-
disturbing activity and/or (2) the land owner or person in possession or control of the land when they have directly or
indirectly allowed the land-disturbing activity or have benefited from it and (3) the named party on the Land Disturbing
Permit.
CT Clean-Durham, LLC
Name
4343 Von Karman Ave Suite 200
Street Address
Newport Beach CA 92660
City State Zip
[phone]
Telephone Fax Email
The Sedimentation and Pollution Control Act (Act) and the Durham City-County Unified Development Ordinance
(Ordinance)includes,but is not limited to,the following legal obligations of the financially responsible party:
• Maintain a set of approved sedimentation and erosion control plans,if required,on site.
• Display permit on site.
• Understand and implement any required plan,including the construction sequence and details.
• Inspect,maintain and repair sedimentation and erosion control measures,especially after rainfall events.
• Provided adequate ground cover or otherwise stabilize all areas that have not been actively graded within 21 calendar
days.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
201 E.Main St,5th Floor,Durham,N.C.27701• [phone]•Fax[phone]
www.co.durham.nc.us/ceng

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Corporation Service Company
Name
2626 Glenwood Ave Ste 550
Street Address
Raleigh NC 27608
City State Zip
Telephone Fax Email
7. The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath. I
understand that the person or entity listed on Line 5 above will be: (1)the owner of the Land Disturbing Permit when issued;
(2)responsible for ensuring compliance with the Act and Ordinance;and,(3)will be the only person or entity with standing to
appeal any action taken or decision made by the Sedimentation and Erosion Control Office.
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Telephone Fax Title or Aut P I A , t
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Email Signature
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Business Applicant(Provide corporate resolution on signatory authority)
I, �{m bed/ M. Vander er gl.e ,a Notary Public of the County of Ura.r a ei
State of OAf(fhfin. 01/4_ ,hereby certify that a_rJ-e r . e o i►i
personally came before me this day and acknowledged that he is L1 c r,a I r� Pe"-h-)tr"
of CT-1Cl-tAn--DUrh(Arye (IC and acknowledged,on behalf of
,the due execution of the foregoing instrument.
Witness my hand and official seal,this _ 02 0 " day of Mai- ,20 93
I(4
Notary Public
My commission expires A-D b-e•r ,20 21$
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Individual Applicant
I, ,a Notary Public of the County of
State of ,hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal,this _ day of ,20
Notary Public
My commission expires 20
LAND DISTURBING PERMITS ARE NON-TRANSFERABLE

A notary public or other officer completing this certificate verifies only the
identity of the individual who signed the document to which this certificate is
attached,and not the truthfulness,accuracy,or validity of that document.
STATE OF CALIFORNIA )
)ss.
COUNTY OF ORANGE )
On Ma rG\-- W , 2023, before me, Kimberly M. Vander Riet, a Notary Public, personally
appeared Carter B. Ewing who proved to me on the basis of satisfactory evidence to be the person
whose name is subscribed to the within instrument and acknowledged to me that he executed the same
in his/her/their authorized capacity, and that by his signature on the instrument the person, or the entity
upon behalf of which the person acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
4 SE�l QI Th• KIMBERLY M.VANDER RIET WITNESS my hand and official seal.
Notary Public-California z
W
y-i'' OTT County;m 8
Z ;•<,N51.1 i; Commission itT423377
My Comm.Expires Oct 24,2026 /'

Provide a Notarized Item 8 for each landowner listed in Item 4.
8. Land Owner Consent. As a landowner,I provide my consent for land-disturbing activities to occur on the property listed in
Item 2 by the person or entity listed in Item 5.
03/c23/02.3 TWO M S F A-P-.t) Ernl�J
Date Type or Print Name
1111 OM1/1
Telephone Fax Titl- or Aut
1,14 _4
Email Sig ature
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Business Landowner(Provide corporate resolution on signatory authority)
I, L-y 0• S ,a Notary Public of the County of i/`ukK E
State of N®g1+ i-//J A ,hereby certify that NZ n/4 5 F. D ®
personally came before me this day and acknowledged that he is M I-iJ/A-
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of CHEWOKEE PrbPed}tc-3/ and acknowledged,on behalf of C itagote 1'11)1 Er.1
1fe0'P ! ,the due execution of the foregoing instrument.
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Witness my hand and official seal,this �3 day of lid{- ,20 c23
/f'!f1 y OZ Notary Public
My commission expires ,20 Z 3 .
*********************************************************************************************************************************
Individual Landowner
I, ,a Notary Public of the County of
State of ,hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal,this day of ,20
Notary Public
My commission expires 20
SE-03 Rev.07/06
Kimberly D. Shaw
NOTARY PUBLIC
Wake County
North Carolina
My Commission Expires merf 0z►�

4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
Raleigh Concrete LLC
Name
4107 Mitchell Mill Rd
Address
Raleigh NC 27616
City State Zip
Telephone Fax Email

Provide a Notarized Item 8 for each landowner listed in Item 4.
8. Land Owner Consent. As a landowner,I provide my consent for land-disturbing activities to occur on the property listed in
Item 2 by the erson or entity listed in Item 5.
3/ 2-j23 ---QalE�9� C� ors. u-�
Date Type or Pri4r(Name
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Tel Fax Title o
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Email Signature
Business Landowner(Provide corporate resolution on signatory authority)
I,S O►rr►Art V f i hL Sevi 11'1 ,a Notary Public of the County of V,/q vc e
State of No rk CeArot i MA ,hereby certify that"6re..1 A a IAoq LiP-
personally came before me this day and acknowledged that he is V(7 0+ Ope. tt4-i 0n3
ofla‘a l e q k C,d✓1Lre j{• Girt. and acknowledged,on behalf of 12%40 e i✓q in �� r1 c,re k. 1-/i C.
,the due execution of the foregoing instrument. S AM ANTA U R 16 E S EV I L LA
Witness myhand and official seal,this NZ- otary Public, North Carolina
ZZ day of AlM�r� 1- 20 Wake County
�� _,� .� My Commission Expires
Notary Public July 18,2026
My commission expires S-)11 I g ,20 23 .
*********** ********************************************************************************************************************
Individual Landowner
I, ,a Notary Public of the County of
State of ,hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal,this day of ,20
Notary Public
My commission expires 20
SE-03 Rev.07/06