NCC241047_FRO Submitted_20240408

11: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 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 7-Eleven Store#42378
2. Location of land-disturbing activity: Jurisdiction Zebulon (Wake Co. or Municipality)
Highway/Street N.Arendell Ave(NC-96) Latitude 35°50'11.0"N Longitude 78°19'17.4"W
3. Approximate date land-disturbing activity will commence: January 2024
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 4.30
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Nick Carroll E-mail Address [e-mail]
Telephone [phone] Cell # Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Carl Victor Tart Jr and Vickie Newton Tart Burlington
Name(s) Telephone Fax or E-mail address
7815 Roxboro Road
Current Mailing Address Current Street Address
Bahama NC 27503-9045
City State Zip City State Zip
8. Deed Book No. 1465,2755 Page No. 154,492 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):
Andrew Laing, C4 CStore Holdings III,LLC [e-mail]
Name E-mail Address
801 East Boulevard
Current Mailing Address Current Street Address
Charlotte NC 28202
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:
Chris Taft [e-mail]
Name E-mail Address
2020 Progress Court,Suite 100-110
Current Mailing Address Current Street Address
Raleigh NC 27608
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:
Paracorp Incorporated
Name of Registered Agent E-mail Address
176 Mine Lake Ct#100
Current Mailing Address Current Street Address
Raleigh NC 27615
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.
Andrew Laing Authorized Signatory
Type or print name Title or Authority
JI
/ 10/9/2023
Signatta e \/- Date
I, Vi -":‘ , a Notary Public of the County of WW1 t x b ul`�
State of North Carolina, hereby certify that jorNa -eu) LCLA elCk appeared
personally before me this day and being duly sworn acknowledged that the abovem was executed by him.
Witness my hand and notarial seal,this 9- day of Q Ok3t.r- , 20
‘0 sTIN R//ii
0: Not
Seal if N° 't G \� aO
n = My commission expires