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HomeMy WebLinkAboutNCC221335_FRO Submitted_20220406O-W WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM P=7 SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land -disturbing activity on one or more acres as covered by the Wake 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 NOR IH (ARo„NA 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 GNICBuildinq Expansion 2. Location of land -disturbing activity: Jurisdiction Zebulon (Wake Co. or Municipality) Highway/Street E Gannon Ave Latitude 35,827 Longitude-78.307 (NC Hwy 97) 3. Approximate date land -disturbing activity will commence: N m r 15 2021 4. Type of development (residential, commercial, industrial, institutional, etc.): Industrial 5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 8.10 acres 6. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Linda Arnold Telephone (919) 877-8668 Cell # (919) 931-1841 Fax # 7. Landowner(s) of Record (attach accompanied page to list additional owners): TEB 0, LLC (919) 877-8668 _ mark@tmeinvestments.com Name(s) Telephone Fax or E-mail address 10729 Tre o Trail 1300 Chatsworth Ln Current Mailing Address Current Street Address Raleigh NC 27614 Raleigh NC 27614 City State Zip City State Zip 8. Deed Book No. 16455 Part B. Page No. 2641 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): TEB 0, LLC Name 10729 Trego Trail Current Mailing Address Raleigh City mark@tmeinvestments.com E-mail Address 1300 Chatsworth Ln Current Street Address NC 27614 Raleigh NC 27614 State Zip City State Telephone (919) 877-8668 Fax Number ZJp 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: N/A Name Current Mailing Address City Telephone, E-mail Address Current Street Address State Zip City State Zip 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: N/A Name of Registered Agent Current Mailing Address City State Zip E-mail Address Current Street Address City Telephone Fax Number State Zip 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. Mark Andrews Type or pLrsnt nagne Signature d►d!j1'y- Title or Autho ity -� I -�' 7'o Date k a Notary Public of the County of State of North Carolina, hereby certify that TJ 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 5� 1 day of _MaYC1 20 a� ' LISA L. MARKEY E Notary Public, North Carolina. Wake County Notary My Commission Expires June 25, 2023 My commission expires QUU02 02�02 3