NCC230379_FRO Submitted_20230209

WAKE COUNTY FINANCIAL RESPONSIB|LITYIOWNERSHWP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WAUCounty Unified Development Ordinance before this hznn and on acceptable erosion and
couNTY sedimentation control plan have been onmp|abad and approved byWake County Department of
Environmental Sorvivas, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
�01WG��8�D�e
1. Project Name
2. Location ufland-disturbing activity: Jurisdiction Garner (Wake Co. orMunicipality)
Highway/Street VVaterfie|dDrive Latitude 35680661 Longitude '78.581898
3. Approximate data land -disturbing activity will commence: September2O22
4. Type of development (residential, commercial, industrial, institutional, etc.): Light Industrial
5. Total acreage disturbed or uncovered (including off -site utilities and bunnvwkwonha
areas): 3.5 acres
Ei Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Num Jimbo0xon
E-mail Address
Telephone 819`828-6609ex 122 Cell
# 918'247'3817 Fax# 919'828'6698
7. Landowner(s) of Record (attach accompanied
page to list additional owners):
Vanguard Vt || EA3LLC
918'828-8609 [e-mail]
Name(s)
Telephone Fax orE-mail address
G29Oberlin Road
620Oberlin Road
Current Mailing Address
Current Street Address
R8|8iOh' NC 27605
RG|eigh, NC 27605
City State Zip
City State Zip
O. Oood8oVkNo. 019026 Page No.
00819 Provide ocopy ofthe most current deed.
Part B.
1. Person(s) or firm(s) who are financially
responsible for the land -disturbing activity (Provide o
comprehensive ||at of all responsible parties on an attached sheet. Include requested information):
A.B.Goodrich Contracting, LL{|
[e-mail]
Name
E-mail Address
S2QOberlin Rd
G2QOberlin Rd
Current Mailing Address
Current Street Address
Raleigh, NC 27605
Raleigh, NC 27605
City State Zip
City State Zip
Telephone 919'828-8689
Fax Number 919'8286698

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 State
Telepho
E-mail Address
Current Street Address
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 State
Telepho
E-mail Address
Current Street Address
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.
'4e G�VAA
Type or print name Title or Auth ity
- 01 Q fd vv
Signa ure Date
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I , 4amlieepi C' Onar Ae , a Notary Public of the County of Wa
State of North Carolina, hereby certify that A appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my
m%/
KATHLEEN C. SHARPE—
WnMY PUBLIC
Wake CM*
NO&CWONN
My CwMkflon E*kn AprN 6, 2023
I 20�-
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My commission expires