NCC242323_FRO Submitted_20240806

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
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
Jones Dairy Storage Facility
1. Project Name
2. Location of land-disturbing activity: Jurisdiction Town of Rolesville (Wake Co. or Municipality)
Highway/Street Jones Dairy Road Latitude35•949571 Longitude -78.46960
3. Approximate date land-disturbing activity will commence: November 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): 5.77 Acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian Holder E-mail Address [e-mail]
Telephone [phone] Cell# 919-896-0875 Fax# N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
SUZANNE SHOAF WARD _ N/A N/A
Name(s) Telephone Fax or E-mail address
10925 ENCHANTED HOLLOWAY 10925 ENCHANTED HOLLOWAY
Current Mailing Address Current Street Address
RALEIGH, NC 27614 RALEIGH, NC 27614
City State Zip City State Zip
8. Deed Book No. 15069 Page No036 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):
Rivercrest Realty Associates, LLC [e-mail]
Name E-mail Address
8816 SIX FORKS RD, SUITE 201 8816 SIX FORKS RD, SUITE 201
Current Mailing Address Current Street Address
RALEIGH, NC 27615 RALEIGH, NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
Jonathan Gaines [e-mail]
Name of Registered Agent E-mail Address
8816 SIX FORKS RD, SUITE 201 8816 SIX FORKS RD. SUITE 201
Current Mailing Address Current Street Address
RALEIGH, NC 27615 RALEIGH, NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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.
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Type or print name Title or Authority
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Signature Date
1 I ela- I1 I-6 D`1 . a Notary Public of the County of Wa1
State of North Carolina, hereby certify that .hGL4 han acgi h e S 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 }L day of OC b-er , 20 D-3
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