NCC233414_FRO Submitted_20231121

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
County i Deec be acceptabo
COUNTY sedimentationUnif ed controlv planlopment haveOrdinan been completedeefor
and this approvedform byand an Wake County le Departmenter sion ofand
NORTH CAROL!NA 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 Wendell Falls Flex Construction Documents
Wendell
2. Location of land-disturbing activity: Jurisdiction (Wake Co. or Municipality)
Wendell Valley Boule 35° 79' 09" N 78°25'47"W
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence
Summer 2023
4. Type of development(residential, commercial, industrial, institutional, etc.):
Residential
5 Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas) 40.12
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tanya Matzen E-mail Address tanya.matzen@brookfieldpropertiesdib
Telephone[phone] Cell# [phone] Fax#
7 Landowner(s) of Record (attach accompanied page to list additional owners)
Nash Wendell Falls, LLC [phone]
Name(s) Telephone Fax or E-mail address
13777 Ballantyne Corporate Place, Suite 500 Same as Mailing Address
Current Mailing Address Current Street Address
Charlotte NC 28277
City State Zip City State Zip
8 Deed Book No.015478/016648 Page No 01623/00594 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):
Nash Wendell Falls, LLC [e-mail]
Name E-mail Address
13777 Ballantyne Corporate Place, Suite 500 Same as Mailing Address
Current Mailing Address Current Street Address
Charlotte NC 28277
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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_
byme 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.
Tanya Matzen VP, Operations
Type or print name Title or Authority
Signature Date
1
1, A- vt , a Notary Public of the County of a v'CLIACid-C
State of North Carolina, hereby certifythat IC� 1 •1ct kla_tZ�4/1 appeared
personally before me this day and being duly sworn acknowledgJl that the above form was executed by him.
Witness my hand and notarial seal, this 1t-\ day of .6 h e t/ , 20 Z"
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N ',, Notary r -
",Kc A R y My comr'n.gsion expires i;c/ l_ /ZQ?5
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