NCC230548_FRO Submitted_20230228

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
NORM CAROHNA I 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 WAKE COUNTY VETERANS AFFAIRS OUTPATIENT CLINIC
2. Location of land -disturbing activity: Jurisdiction GARNER (Wake Co. or Municipality)
Highway/Street 2700 BENSON RD Latitude 35039'19.51" N Longitude 78°36'53.37"W
3. Approximate date land -disturbing activity will commence: 11/01/2022
4. Type of development (residential, commercial, industrial, institutional, etc.): COMMERCIAL
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1S.o8
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity. -
Name IASON RAINEY, PE E-mail Address [e-mail]
Telephone [phone] Cell # 828-455-2134 Fax # [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
900 Rand Road LLC 971-413-1204 [e-mail]
Name(s)
Telephone Fax or E-mail address
100 N. City Parkway, ste
1520
Same
Current Mailing Address
Current Street Address
Las Vegas NV
89106
City State
zip
City State zip
8. Deed Book No. 018370
Page No.
01400 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):
900 Rand Road TLC
[e-mail]
Name
Email Address
100 N. City Parkway, ste
1520
Same
Current Mailing Address
Current Street Address
Las Vegas NV
89106
City State
.Zip
City State Zip
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:
Fred Smith Company
Name
6105 Chapel Hill Rd.
Current Mailing Address
Raleigh NC 27607
City
E-mail Address
Current Street Address
State Zip City
Telephone [phone]
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:
900 Rand Road LLC
Name of Registered Agent
[e-mail]
E-mail Address
100 N City Parkway, ste 1520 same
Current Mailing Address Current Street Address
Las Vegas NV 89106
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.
Mike Doran
Type or print name
Signature
--------------------------------------------------------------
its' Authorized Agent
Title or Authority
1/21/2023
Date
1, C-&r"a AL1CjChaq-e- -,a Notary Public of the County of(2.0'ldWQM
State of North Carolina, hereby certify that 0 ! j k__t a lro n 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 _ _ _day of , 20�
_ tary
� GUOR1A OMKHALT�
Xc"Zirj Pubiic My commission expires
Caldwell County, North Carolina
My Cornrnissbn Expires
Septembor 11, 2024