NCC243053_FRO Submitted_20241009

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the 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
NORTH CAROLINA 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 Brownfield Road C&D Landfill-Phase 3
2. Location of land-disturbing activity: Jurisdiction Wake Co. (Wake Co. or Municipality)
Highway/Street Brownfield Road Latitude 35.11541 Longitude -78.498809
3. Approximate date land-disturbing activity will commence: September 23, 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): 44.6
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Scott Kamp E-mail Address [e-mail]
Telephone Cell# [phone] Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Wake Reclamation, LLC [phone]
Name(s) Telephone Fax or E-mail address
2600 Brownfield Road 2600 Brownfield Road
Current Mailing Address Current Street Address
Raleigh NC 27610 Raleigh NC 27610
City State Zip City State Zip
8. Deed Book No. 014701 Page No. 01898 _ 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):
Wake Reclamation. LLC
Name E-mail Address
2600 Brownfield Road 2600 Brownfield Road
Current Mailing Address Current Street Address
Raleigh NC 27610 Raleigh NC 27610
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:
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:
Travis Hitchcock [e-mail]
Name of Registered Agent E-mail Address
3301 Benson Drive, Suite 601 3301 Benson Drive, Suite 601
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
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 information provided herein.
Travis Hitchcock Regional Vice President(GFL Environmental)
Type or print na a Title or Authority
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natur----271e Date
e Yvor. , a Notary Public of the Countyo of YtQrYlble.n
State of North Carolina, hereby certify that Tom'�S 1'2tAC MCOCIC appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial se 's day of See\-' , 20 �y
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