NCC200427_ESC Approval Submitted (2)_20200226

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WEENo 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
NORTH CAROLINA 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 White Oak Northwest Subdivision- Medical Office Building
2. Location of land -disturbing activity: Jurisdiction Garner, NC (Wake Co. or Municipality)
Highway/Street Cabela Drive Latitude 35.698851 Longitude-78.586646
3. Approximate date land -disturbing activity will commence: February 2020
4. Type of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 5.2 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ana Wadsworth, PE E-mail Address [e-mail]
Telephone [phone] Cell # 813-505-99002 Fax # --
7. Landowner(s) of Record (attach accompanied page to list additional owners):
White Oak NW Associates, LLC 704-342-0410 [e-mail]
Name(s) Telephone Fax or E-mail address
831 E. Morehead Street #445 Same
Current Mailing Address Current Street Address
Charlotte, NC 28202 _
City State Zip City
State
Zip
8. Deed Book No. 016141 Page No. 00824 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):
Garner White Oak NW MOB, LLC & [e-mail] &
White Oak NW Associates, LLC [e-mail]
Name E-mail Address
9113 Cameron Wood Drive &
831 E. Morehead Street #445 Same
Current Mailing Address Current Street Address
Charlotte, NC 28210 &
Charlotte, NC 28202
City State Zip City State Zip
704-618-1153 &
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:
Ana Wadsworth, PE
Name
130 Pardo Street
Current Mailing Address
Garner, NC 27529
City State
Telephone [phone]
aadsworth @burtoneng. com
E-mail Address
Same
Current Street Address
Zip City
Fax Number
State Zip
(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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone 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.
amQ.. CV t k' D.A' cc( -
Type or print namk$���s� L _ Title or Autho
Date
_ \ 'w, , a Notary Public of the County of
State of� North Carolina, hereby certify that f 11 ��i�L (� appeared
personally before me this day and being duly sworn acknowled ed that the above form was executed by him.
Witness my hand and notarial seal, this _ day of dC G F 20
t
Li
Notary > J
My commission expires_

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:
Ana Wadsworth, PE
Name
130 Partlo Street
Current Mailing Address
Garner, NC 27529
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
Same
Current Street Address
City State Zip
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:
Joshua A. Teague_
Name of Registered Agent
9113 Cameron Wood ❑r
Current Mailing Address
josh. tea g u e@ restra teg i e s. corn
E-mail Address
Current Street Address
Charlotte NC 28210 Same
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.
Joshua A. Teague Manager - Garner White Oak NW MOH, LLC
Typ or name Title or Authority
A�A1117
Sign re Date
---------------
I, 4, a Notary Public of the Country of
State of North Carolina, hereby certify that r lea m 4appeared
personally before me this day and being duly sworn acknowledged that the a ❑ve form was executed by him.
Witness my hand and notarial seal, this _;�5 day of llC�0/2ej- , 20Iq_
Caio Qe Brito
-44QTARY PUBLIC Notary
Mecklenburg County, NC My commission expires Ak' 2D2-3 _
My Commission Expires October 14, 2023