NCC191004_ESC Approval Submitted (2)_20190717

EW-M 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
AKE 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.
1. Project Name Wendell Valley Boulevard
2. Location of land-disturbingactivity: Jurisdiction Wendell
Y (Wake Co. or Municipality)
Knightdale Eagle —78 . 426507
Highway/Street Rock Road Latitude 35 . 791902 Longitude
3. Approximate date land-disturbing activity will commence: Spring 2019
4. Type of development(residential, commercial, industrial, institutional, etc.):Residential/Commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 11.73 Acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Lee Bowman E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
NASH Wendell Falls, LLC 919-951-0700 [e-mail]
Name(s) Telephone Fax or E-mail address
66133 Taylor Road 6133 Taylor Road
Current Mailing Address Current Street Address
Wendell, NC 27591 Wendell, NC 27591
City State Zip City State Zip
8. Deed Book No. 015478 Page No. 01623 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):
NASH Wendell Falls, LLC [e-mail]
Name E-mail Address
6133 Taylor Road 6133 Taylor Road
Current Mailing Address Current Street Address
Wendell, NC 21591 Wendell, NC 27591
City State Zip City State Zip
919-951-0700
Telephone 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
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.
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Type or print name Title or Authority
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Signature Date
I, L. a Notary Public of the County of DLA_, yy�n
State of North Carolina, hereby certify that =t_ L_,?_C. -,I, rr -,� 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 Klo,re A�q r 20 I g
Notary
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