NCC242538_FRO Submitted_20240820

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
111W
7No 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
,,p ti 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: Rolesville Road Gap
2. Location of land-disturbing activity: Jurisdiction Town of Rolesville/NCDOT (Wake Co. or Municipality)
Highway/Street Rolesville Rd Latitude 35D53'23"/35D53'8" Longitude 78D26'47"/78D26'51"
3. Approximate date land-disturbing activity will commence: TBD
4. Type of development(residential, commercial, industrial, institutional, etc.: Road Improvements
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1.60 ac.
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brad Haertlina E-mail Address bHaertlingaamerican-ea.com
Telephone [phone] Cell# 919-605-5562 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
NCDOT (Daniel Boulware) 919-814-6115 919-715-5778
Name(s) Telephone Fax or E-mail address
1575 Mail Service Center 4009 District Drive
Current Mailing Address Current Street Address
Raleigh NC 27699 Raleigh NC 27607
City State Zip City State Zip
8. Deed Book No. 11940, 12007 Page No. 1155, 2228 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):
Mitchell Mill Road Investors LLC karlftrestondev.com
Name E-mail Address
100 Matrix Drive 8000
Current Mailing Address Current Street Address
Cary NC 27513
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 an y
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:
/ k.,\10.h ' 'Gw [e-mail]
Name of Registered Agent E-mail Address
100 Matrix Drive 8000
Current Mailing Address Current Street Address
Cary NC 27513
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 informationPrRst-a-evit
provided herein.
S .`10.V1 W w V t Ct
Type or prin nam Title or Authority
4\SO \aoay
Signature Date
I, mar), , a Notary Public of the County of WG` +e
State of North Carolina, hereby certify that k1\O_,(\ V) Wt� 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 day of Ap , •1 I , 20 O� 1
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