NCC241083_FRO Submitted_20240410

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
..„,.....ar. ,_ 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�,��«,�IN.\ 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 NC Supply Chain Center Warehouse Truck Lot Renovation
2. Location of land-disturbing activity: Jurisdiction Wake Co. (Wake Co. or Municipality)
Highway/Street 3100 Waterfield Dr. Latitude N35 DEG 40'48.91" Longitude W78 DEG 33'31.44"
3. Approximate date land-disturbing activity will commence: March 2024
4. Type of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 2.34
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kendall Moore E-mail Address [e-mail]
Telephone [phone] Cell # Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Kolligian Group LP 310-922-0721 [e-mail]
Name(s) Telephone Fax or E-mail address
8050 N. Palm Ave St. 300 SAME
Current Mailing Address Current Street Address
Fresno, CA 93711
City State Zip City State Zip
8. Deed Book No. 016647 Page No. 01212 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):
Domino's Pizza Master Issuer LLC [e-mail]
Name E-mail Address
30 Frank Lloyd Wright Dr. same
Current Mailing Address Current Street Address
Ann Arbor MI 48106
City State Zip City State Zip
Telephone [phone] Fax Number NA

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:
Carrie Ballew [e-mail]
Name of Registered Agent E-mail Address
30 Frank Lloyd Wright Dr. same
Current Mailing Address Current Street Address
Ann Arbor MI 48106
City State Zip City State Zip
Telephone [phone] Fax Number NA
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.
Carrie Bellew Vice President- Procurement
Type or print name Title or Authority
bl-L6-"CAAF-- /
Signature Date
I, N ( C-U I-e Stowe , a Notary Public of the County of Was\q±e m)
State of -North� t c a, hereby certify that l_C.r ri e BOJ l e w appeared
personally before me this day and being duly sworn acknowledged thatthe above form was executed by him.
Witness my hand and notarial seal, this 12- day of rn.C&-rCY . , 20 24
Notary
Seal I ? A{ /20 2 My commission expires
NL STOWE
NOTARY PUBLIC,STATE OF MI
COUNTY OF WASHTENAW
MY COMMISSION EXPIRES Nov 24,2024
ACTING IN COUNTY OF Was� cui f

� I
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:
William James [e-mail]
Name E-mail Address
3100 Waterfield Dr. Same
Current Mailing Address Current Street Address
Garner NC 27529
City State Zip City State Zip
Telephone [phone] ext. 1222 Fax Number NA

February 27, 2024
Town of Garner, North Carolina
Ladies and Gentlemen,
On behalf of Domino's Pizza, Inc. and its subsidiaries, I hereby confirm that Ms. Carrie Ballew, as Vice
President, Procurement and Replenishment of Domino's Pizza LLC, has the requisite corporate
authorization to sign agreements on behalf of Domino's Pizza Master Issuer LLC.
Please let me know if you require any further information.
Yours Trul
(//(A w
Name: r. osctio,,kw l e nr�
Title: U,'cv: re,5 1'8--o_A-.�t c J. Ass; rs. c�
Section 6 - Contracts
6.1 VENDOR CONTRACTS
Contracts which involve spend executed by Domino's Pizza, Inc. or any of its subsidiary entities. All
contracts must be signed/executed by a VP or higher within the contracting system (currently Ariba)
following applicable review. Multi-year agreements must combine all committed obligations together
when determining the required level of authorization(s).
Domino's Pizza, Inc. 30 Frank Lloyd Wright Drive • Ann Arbor, MI 48105