NCC223909_FRO Submitted_20221130

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
s , No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
W 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
NUR„3 CARM IN% Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Proiect Name
2. Location of land -disturbing/ activity: .Jurisdiction A VC (Wake Co. or Municipality)
Highway/Street i n50(e_ �� JA-11 Latitude 35 • ?F-7 36 F( Longitude
3. Approximate date land -disturbing activity will commence: 2 - 20 " 2D2Z
4. Type of development (residential, commercial, industrial, institutional, etc.): !�?jr we, �c e. ( _
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): p . V92
B. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
7
Name_ 5 Ic>f e5 _ E-mail Addressy�rl CUB
Telephone Cell #i ' ��� ��� Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Me'zL( �v��9 AdKe-J l(°l--i�o-lg-le
Name(s) Telephone
Current Mailing Address
wt i�e F� re k6 '9 (75 g-7
City State Zip
Jt`--(f
Current Street Address
City
State
Fax or E-mail address
Zip
8. Deed Book No. 019 795Page No. QQ q � 6 Provide a copy of the most current deed_
Part B.
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 informationn)):
��✓�r rLf L�/ � t`�DIMG°5 n��ll Gu nf�tGrO.���� x��jc� l/ eo
Name E-mail Address
g17 '5_ w���� ':5�
Current Mailing Address Current Street Address
WAke Fofez tiz 2 tzst�
City State Zip City
Telephone qlq - -�l 0 (5� l & Fax Number
State
Zip

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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip
Telephone
City
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. rein.J('� Trem / (ez-p-4"_
Type or print name Title or Authority
-� _X022
Signs fure Date
a Notary Public of the County of
State�0401 ►fQarolina, hereby certify that L 5 y/ Ji�G _ appeared
per j 4his day and being duly sworn acknowledged that the above form was executed by him.
)Atnelk m�6r hani Atarial seal, this ZEday of 20 �a
y 5 Qc�
�' •'jC
Notary
-���►!lillL�JI`�6*� My commission expires