NCC221439_FRO Submitted_20220413

1p�w WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=1 SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WEE
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 NIA in the blank.)
Part A.
1. Project Name Rollman Farms
2. Location of land -disturbing activity: Jurisdiction Wake County_- Garner (Wake Co. or Municipality)
Highway/Street Old Stage Rd Latitude 35.6875 Longitude-78.6541
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 50.2
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Hampton Smith E-mail Address [e-mail]
Telephone Cell # [phone] Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Rollman Properties, LLC
Name(s) Telephone Fax or E-mail address
904 Wakestone Ct, 904 Wakestone Ct.
Current Mailing Address
Raleigh, NC 27609
City State
8. Deed Book No. 011699
Current Street Address
Raleigh, NC 27609
Zip City State Zip
Page No. 02719 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 attach d sheet. Include requested information):
ARS Garner -Old Stage Development, LLC , &QQC0Vi (,IA. -
Name E-mail Address
1524 Canterbury Road _ 1524 Canterbury Road R_
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number n/a

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
0 14 'q" 14 ta, S&-(
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Type or prin ame io Title or Authority
Signature V oyDate
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I, a Notary Public of the County of 104_-
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State of North Carolina, hereby certify that QV)r Ij6, � appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
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Witness my hand and notana, seal. this day of % Ly'i .4,i, 20 Z j
DUSTY DRAKE BATTEN
NOTARY PUBLIC Not ry
Ske County Q
North Carolina My commission expires