NCC220131_FRO Submitted_20220107

OW-M 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
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 4700 Guy Road
2. Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street Guy Road Latitude 35.67240 Longitude -78•s1959
3. Approximate date land -disturbing activity will commence: November 1, 2021
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•03
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameSonny Bannister E-mail Address [e-mail]
Telephone [phone] Cell # �11q'31�1 -$�`� 7 . Fax # q\`�
7. Landowner(s) of Record (attach accompanied page to list additional owners):
D&S Properties, LLC
Name(s)
PO Box 1238
Current Mailing Address
Garner
City
8. Deed Book No 017N2
Part B.
Telephone
Current Street Address
NC 27529
State Zip City
Page No. 01435
State
Fax or E-mail address
Zip
Provide a copy of the most current deed.
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):
D&S Properties, LLC sonny royal(k9bellsouth.net
Name E-mail Address
PO Box 1238
Current Mailing Address
Garner NC 27529
Current Street Address
City State Zip City State Zip
Telephone [phone] Fax Number ') C) — IS W

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:
Rolly Bannister III [e-mail]
Name of Registered Agent E-mail Address
PO Box 1238
Current Mailing Address Current Street Address
Garner NC 27529
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.
Roily Bannister III
Type or print name/
Title or Authority
Signature Date
-------
MOW : s -,a Notary Public of the County of Vj ('1Lt_
State of North Carolina, hereby certify that _�el)y�)(Ann) s1c< iI appeared
personally before me this day and being duly swom acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 3Cr�day of .SeO20al
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Notary
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