NCC221990_FRO Submitted_20220527

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No 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
I'll (AK 11 Environmental Services, Water Quality Division. (Please type or print and, if the question is not
7� applicable, place N/A in the blank.)
Part A.
I - Project Name Chandlpr Hiallson Concrete PLant
2. Location of land -disturbing activity: Jurisdiction Mke Co. (Wake Co. or Municipality)
Highway/Street'05�D Pordorw:�� 5urvi�;(� RuLatitude 35,9369 Longitude _7gssil
3. Approximate date land -disturbing activity will commence: __Ap61202?___
4. Type of development (residential, commercial, industrial, institutional, etc-) IrAti-Mriiii
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas). A 2 ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Narne Jamie Nelms — E-mail Address Jamie.Nelms@Chani:HorConcrele.com
Telephone [phone] Cell # 33a.510:2sss Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
jjansm�,k
q�Tga
H 919-614-1163 Dp_m_n.McMcifi;iMLehHarsan.com
Name(s) Telephone Fax or E-mail address
10501 Capital Blvd.
Current Mailing Address
Wake Forest, NC 27587
city State Zip
10501 Capital Blvd.
Current Mailing Address
Wake Fares, NC 27587
city State Zip
8. Deed Book No._is5m —Page No. 2n97 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):
- -Ch "narf',oRgretei_
Name
10009 S Chtrnh St.
Current Mailing Address
E-mail Address
1006 a Church St.
Current Street Address
surlin2ton, NG 27215 Budington, NC 27215
City State Zip City State Zip
Telephone 11gl 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:
Daren McMorris
Name
Daren.McMor(isDIehiahhanson.com
E-mail Address
10501 Capital Blvd. 10501 Capital Blvd.
Current Mailing Address Current Mailing Address
Wake Forest, NC 27687 Wake Fafest, NC
City State zip &t-y­ __ __ State
Telephone [phone] Fax Number
'>7587
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 State
E-mail Address
Current - Street Address
zip- cilt y_
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.
Jamip_ NeImS
Type or print name
,A%' nature
-Dirprj rpf Mratinng Chaad1.V_r_(nnrrpta
Title or Authority
:2/.'L5/2
Date
a Notary Public of the County of
State of North Carolina, hereby certify that -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 ;Z 5—lay oN.
Phyllis A Gorman
NOTARY PUBLIC Notary
Alamance County, NC
My commission expires::� :—)C)