NCC216803_FRO Submitted_20211213

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FUQUA2f-1/1-1R 1, NA
Financial Responsibility/Ownership Form SPCA
See TOFV LDO, Section §9-1407 SOIL EROSION & SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
Part A.
1. Project Name Discount Tire Fuguay Varina
2. Location of land -disturbing activity: Highway/Street_ 1260 N. Main Street
3. Approximate date land -disturbing activity will commence: 12121
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 1.39+- AC
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Daniel Nelms _E-mail Address [e-mail]
Telephone 704-91
Cell # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
National Retail Properties investorreiationsAwww.nnnreit.com
Name E-mail Address
450 S Orange Avenue Suite 900 450 S_Orange Avenue Suite 900
Current Mailing Address Current Street Address
Orlando FL 32801
City State Zip
Orlando FL 32801
City State Zip
8. Deed Book No. 017017 Page No. 02543-02550 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):
Halle Properties LLC Discount Tire of North Carolina constructionpdiscounttire.com
Name E-mail Address
20225 N Scottsdale Road 20225 N Scottsdale Road
Current Mailing Address Current Street Address
Scottsdale AZ 85255 Scottsdale AZ 85255
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varina - 401 Old Honeycutt Road, Fuquay-Varina, NC 27526
[phone] E fuquay-varina.org

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 Town of
Fuquay-Varina Land Development Ordinance and/or Land Disturbance Permit:
Name
N/A
Current Mailing Address
N/A
City State Zip
N/A
E-mail Address
N/A
Current Street Address
N/A _
City State Zip
Telephone 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:
Danielle Faust, Corporation Service Company danielle.faust csc Iobal.com
Name E-mail Address
2626 Glennwood Ave STE 550 2626 Glennwood Ave. STE 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Telephone [phone]
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.
Matthew Johnson, Agent
Type or print nar a Title or Authority
7/27/2021
Siff nature Date
I, Danna M arner , a Notary Public of the County of Marico a
State of Arizona, hereby certify that Matthew Johnson appeared personally
before me this day and being duly sworn acknowledgeYU
the above form was executed by him.
Witness my hand and notarial seal, this l4 day of 21
DONNA M WARNER ��'``�
Notary Public Notary
Maricopa County, Arizona
Seal My Comm. Expires 04-W24
R Commission No. 581521
4/6/2024
My commission expires