NCC217135_FRO Submitted_20211228

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
X.M.
PNo person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAKECounty 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 (:A ROLI NA 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 Clancy & Th
2. Location of land -disturbing activity: Jurisdiction Town of Garner (Wake Co. or Municipality)
Highway/Street Spaceway Ct. Latitude 35.6765 Longitude-78.5490
3. Approximate date land -disturbing activity will commence:
December 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 4.2
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Richard R. Herring, PLS E-mail Address rherringp_herring-sutton.com
Telephone
252-291-8887
Cell # 252-399-1858 Fax # [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
T&R Grading and Investment, LLC 919-834-3601
Name(s) Telephone Fax or E-mail address
PO Box 27608
Current Mailing Address
Raleigh NC 27611
City State Zip
8. Deed Book No
Part B.
18609
Page No
421 N. Harrinaton St. - Suite 200
Current Street Address
Raleigh NC �p
City State Zip
1405 Provide a copy of the most current deed.
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):
T&R Grading and Investment, LLC - Fleming Herring [e-mail]
Name E-mail Address
PO Box 27608
Current Mailing Address
421 N. Harrington St. - Suite 200
Current Street Address
Raleigh NC 27611 Raleigh NC M�_3
City State Zip City State Zip
Telephone
919-834-3601
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Fleming Herring, P.E.
T e or print name
E
Si at 11-11
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Project Executive �c1
Title or Authority
�0 g7
Date
n 1 l-1lJv-11_, a Notary Public of the County of wo Ll Q
State of North Carolina, hereby certify that r l E.00 �e� �� appeared
personally before me this day and being duly sworn acknowledged thah the above form as executed by him.
Witness my hand and notarial seal, this 22 day of
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Seal
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Notary
My commission expires