NCC222064_FRO Submitted_20220603

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mall and/
or fax information unavailable, place NIA in the blank.)
Part A. Oak View at Siler City
1. Project Name
2. Location of land -disturbing activity: CountyChatham
City or TownshipSller City
Highway/Street Campus Drive Latitude35.723502 Longitude-79.415838
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Multi -Family Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):7.74
6. Amount of fee enclosed: $ 800 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Q
Name Jennifer Lampman
Telephone [phone] cell #
E-mail [e-mail]
Fax ##
Landowner(s) of Record (attach accompanied page to list additional owners):
Chatham County 919-545-8474
Name Telephone Fax Number
PO Box 608
226 Campus Drive
Current Mailing Address
Current Street Address
Pittsboro NC, 27312
Siler City, NC 27344
City State Zip
City State Zip
10. Deed Book No, 0821 Page No. 0639 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the companyorfirm is a sole proprietorship,
the name of the owner or manager may be listed as the
financially responsible party.
Oak View at Siler City, LLC (See attached signature block)
[e-mail]
Name
E-mail Address
160 W Main Street #200
160 W Main Street #200
Current Mailing Address
Current Street Address
New Albany, OH 43054
New Albany, OH 43054
City State Zip
City State Zip
Telephone [phone]
Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Registered Agent Solutions, Inc. clientsupportl @rasi.com
Name E-mail Address
176 Mine Lake Court, Suite 100 176 Mine Lake Court, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Telephone 888`705-7274
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:
Registered Agent Solutions, Inc. clientsupportl @rasi.com
Name of Registered Agent
176 Mine Lake Court, Suite 100
Current Mailing Address
Raleigh, NC 27615
City
State Zip
Telephone [phone]
E-mail Address
176 Mine Lake Court, Suite 100
Current Street Address
Raleigh, NC 27615
City State Zip
Fax Numbe
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.
Jennifer Lampman (see attached signature block) VP Development Signor for Wallick Asset Management LLC
Type or print name
Ign'at ure
Title or Authority
��,�a� See attached Signature Block
Date
-------- ----------------------------------------------------------..-----------------------------------------------------------------
I, C a Notary Public of the County of Fracy-z.1; n
State of a, hereby certify that appeared
personally before me this day and being duly sworn acknowied ed that the above form was
executed by -him.
Witness my hand and notarial seal, this CO� day of RID , 20
C�eJean A Clayton av—a,
Notary Public, State of Ohio Nota
My Commission Expires:
06/19/2026
My commission expires

North Carolina Department of Environmental Quality
Financial Responsibility/Ownership Form Sedimentation Pollution Control Act
Contact Info:
Email: jlarnpman a,wallick.com
Address: 160 W Main Street #200, New Albany, OH, 43054
Phone: [phone]
Project Info:
Project Name: Oak View at Siler City
Property Address/Location: 226 Campus Drive, Siler City, NC 27344
Signature Block
Oak View at Siler City, LLC,
an Ohio limited liability company
By: WAM Oak View at Siler City, LLC,
an Ohio limited liability company,
its sole member
By: Wallick Asset Management LLC,
an Ohio limited liability company,
its sole member
B.
Y Ox��fi'La�
fifer Lam an
Vice President
Notary:
State of Ohio)
County of Franklin) ss:
The foregoing instrument was acknowledged before me, a Notary Public, in and for said county
and state this �Sday of February, 2022 by Jennifer Lampman, Vice President of Wallick Asset
Management, LLC, Sole Member of WAM Oak View at Siler City, LLC, Sole Member of Oak
View at Siler City, LLC on behalf of said limited liability company. This is an acknowledgement
clause; no oath or affirmation was administered to the signer.
�►i maim,
Jean A Clayton
Notary public, State of Ohio
My Commlaslon Expires..
06/19/2026