NCC233790_FRO Submitted_20240103

le. 1 WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the Wake
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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
NORTH FI cntzo��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 500 & 600 Waterfield Ridge Place
2. Location of land-disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street Waterfield Ridge Place Latitude 35.689772 Longitude -78.560459
3. Approximate date land-disturbing activity will commence: September 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Light Industrial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 6.15 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Stephen F. Eisenmann Sr. E-mail Address [e-mail]
Telephone [phone] Cell# Fax*
7. Landowner(s) of Record (attach accompanied page to list additional owners):
500 Waterfield Partners LLC
Name(s) Telephone Fax or E-mail address
3411 Integrity Drive 3411 Integrity Drive
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
8. Deed Book No. 018976 Page No. 01596 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):
Modern Mechanical HVAC LLC [e-mail]
Name E-mail Address
1544 Mechanical Blvd Same
Current Mailing Address Current Street Address
Garner NC 27529
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:
Laura L Eisenmann [e-mail]
Name of Registered Agent E-mail Address
1544 Mechanical Blvd same
Current Mailing Address Current Street Address
Garner NC 27529
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.
Justin Hanlon Managing Member
Type or�tiname Title or Authority
P; ( e/A
Signatur? Date l
I, c `P 1-_e,r(-1- , a Notary Public of the County of U'k2Vr
State of North Carolina, hereby certify that \.):kkA 11 1t,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 - 5 day of ra , 20 •
JULIE LERCH
Notary Public Wake County
No
North Carolina
Seal
Myinmission expires y� i�� k:?,