NCC242271_FRO Submitted_20240725

COP. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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
,,,,,,,,,g,,,,,q 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. Proj ectNameSiemens Parking Expansion
2. Location of land-disturbing activity: Jurisdiction Wa Ice Co unty , (Wake Co. or Municipality)
Highway/Street Siemens Road Latitude_35.817012 Longitude 78.395102
3. Approximate date land-disturbing activity will commence: July 2024
4. Type of development(residential,commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3.0
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name_Justin Jackson E-mail Address [e-mail]
Telephone_(919) 365-7488 Cell# [phone] Fax#
7. Landowner(s) of Record(attach accompanied page to list additional owners):
Siemens Corporation BryanD ekin 9 84-233-9 781 bryan.deki@ cbre.com
Name(s) Telephone Fax or E-mail address
7000 siemens rd wendell NC 200 Wood Avenue South
Current Mailing Address Current Street Address
7000 siemens rd wendell nc City 2759 1 7000 siemens rd wendell nc 2759 1
State Zip - State Zip
8. Deed Book No.16220 Page No.1973 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):
Siemens Corporation [e-mail]
Name E-mail Address
7000 simens rd wendell 7000 siemens rd
NC Current Mailing wendell nc
Address 27` i 1
Wendell NC NC 2759 1 Wendell NC
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:
Justin Jackson [e-mail]
Name E-mail Address
1603 South Hollybrook Road 1603 South Hollybrook Road
Current Mailing Address Current Street Address
Wendell, NC 27591 Wendell, NC 27591
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:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Court Ste. 200 160 Mine Lake Court Ste. 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone 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.
Chris Holt SRE US CE
Typp t na : °' Tti
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uJ�Tv,11 l e , a Notary Public of the County of Kt 611i• ifon
State of , hreby certify that 1 S 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 1S}day of ,20 0� l
aPti '%'%{. •''.itt 's Notary
z My commission expires /(9-0/21.
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