NCC240234_FRO Submitted_20240126

CUP. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
. T No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
w 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 c.nnoi-iNA 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 Tractor Supply
2. Location of land-disturbing activity: Jurisdiction Town of Zebulon (Wake Co. or Municipality)
Highway/Street Old US 264 Latitude 35.828782 N _Longitude-78.293752 W
3. Approximate date land-disturbing activity will commence: May 1, 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): 6.51 ac
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Adam Seliner E-mail Address asellner©primaxproperties.com
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record(attach accompanied page to list additional owners):
Nash MB Properties, LLC
Name(s) Telephone Fax or E-mail address
470 Bass Road
Current Mailing Address Current Street Address
Nashville NC 27856-9296
City State Zip City State Zip
8. Deed Book No. 018852 Page No. 00155 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):
Sea Mountain Ventures II, LLC billseymour©primaxproperties.com
Name E-mail Address
1100 E. Morehead Street
Current Mailing Address Current Street Address
Charlotte NC 28204
City State Zip City State Zip
Telephone [phone] Fax Number

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
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
Noa,r+cARourA 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 Tractor Supply
2. Location of land-disturbing activity: Jurisdiction Town of Zebulon (Wake Co. or Municipality)
Highway/Street Old US 264 Latitude 35.828782 N Longitude-78.293752 W
3. Approximate date land-disturbing activity will commence: May 1, 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): 6.51 ac
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Adam Sellner E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7 Landowner(s)of Record (attach accompanied page to list additional owners):
Old 264 Retail, LLC
Name(s) Telephone Fax or E-mail address
120 Wind Chime Ct
Current Mailing Address Current Street Address
Raleigh NC 27615-6433
City State Zip City State Zip
8. Deed Book No. 019275 Page No. 01185 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):
Sea Mountain Ventures II, LLC [e-mail]
Name E-mail Address
1100 E. Morehead Street
Current Mailing Address Current Street Address
Charlotte NC 28204
City State Zip City State Zip
Telephone [phone] Fax Number _

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 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 cnaOi.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 Tractor Supply
2. Location of land-disturbing activity: Jurisdiction Town of Zebulon (Wake Co. or Municipality)
Highway/Street Old US 264 Latitude 35.828782 N Longitude-78.293752 W
3. Approximate date land-disturbing activity will commence: May 1, 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): 6.51 ac
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Adam Sellner E-mail Address [e-mail]
Telephone [phone] Cell # Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Sea Mountain Ventures II, LLC
Name(s) Telephone Fax or E-mail address
1100 E. Morehead St
Current Mailing Address Current Street Address
Charlotte NC 28204-2815
City State Zip City State Zip
8. Deed Book No. 019275 Page No. 01679 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):
Sea Mountain Ventures II, LLC [e-mail]
Name E-mail Address
1100 E. Morehead Street
Current Mailing Address Current Street Address
Charlotte NC 28204
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:
Bowman North Carolina. Ltd. [e-mail]
Name E-mail Address
4006 Barrett Drive, Suite 104
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:
Marie R. McLucas
Name of Registered Agent E-mail Address
1100 E. Morehead St.
Current Maili.ig Address Current Street Address
Charlotte NC 28204-2815
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.
William G. Seymour Manager
Type or print name Title or Authority
Signature - - Date tOjciLAAA. -a 13
I, Ett ab../1/141 , a Notary Public of the County of ANJ C.1LA_ty-,6AtD,
State of North Carolina, hereby certify that W U._A-Cet., a appeared
personally before me this day and being duly sworn acknowledged that the abo form was executed by him.
Witness my hand and notarial seal, this r 1 day of Alf(,pry-Aik , 20 .2-3
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