NCC230868_FRO Submitted_20230404

"WI 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
WAKECounty Unifi Development be m cab sedimentation ed controlev planlopmen haveOrdinance been completedefor and this approvedfor byand an Wakeac Couneptty le Departmenterosion ofand
COUNTY
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 Valvoline Garner
2. Location of land-disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street Fayetteville Road Latitude 35.667508 Longitude -78.695695
3. Approximate date land-disturbing activity will commence: March, 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.68 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Anthony Andujar E-mail Address [e-mail]
Telephone [phone] Cell# 704-363-2393 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Cambridge-Caddy LLC 704-333-2393 [e-mail]
Name(s) Telephone Fax or E-mail address
831 E Morehead Street, Suite 250
Current Mailing Address Current Street Address
Charlotte NC 28202
City State Zip City State Zip
8. Deed Book No. 019036 Page No. 00159 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):
Southeast Quality Auto, LLC [e-mail]
Name E-mail Address
8000 Tower Point Drive 8000 Tower Point Drive
Current Mailing Address Current Street Address
Charlotte NC 28227 Charlotte NC 28227
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:
Registered Agents Inc [e-mail]
Name E-mail Address
4030 Wake Forest Road Suite 349 4030 Wake Forest Road Suite 349
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Matt McKeown CEO
Type or print name Title or Authority
Signature Date
�Cfz r'\‘7k-e ' � �2 , a Notary Public of the County of
State of North Carolina, hereby certify that V 6c -c- 1�` "�cL Lc v'\ 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 u; day of IZIVA..i,t2,,;M1._r( , 20 .A:C
ROxANNE S MYSZKA O a
N�iPpl Publk- North Carolina
rI Union County My commission expires
My Commission Expires Jul 25, 2027 ` j