NCC221631_FRO Submitted_20220428

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE1 No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
WA 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
MORE h1 (;A Rot INA 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 Sidney Creek Phase 2
2. Location of land -disturbing activity: Jurisdiction Zebulon (Wake Co. or Municipality)
Highway/Street NC HWY 3 9 Latitude 3 5. 8114 7 B Longitude --7 8. 2 68 7 9 9
3. Approximate date land -disturbing activity will commence: Spring 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 37.74
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Randy Talton
E-mail Address [e-mail]
Telephone [phone]
Cell# 919--478-8149 Fax#
7. Landowner(s) of Record (attach
accompanied page to list additional owners):
DRS FA, LLC
Name(s)
Telephone Fax or E-mail address
3000 RDU Center Dr.
Suite 202
Current Mailing Address
Current Street Address
Morrisville NC
27560
City State
Zip City State Zip
8. Deed Boost No. 17910
Page No. 548 Provide a copy of the most current deed.
17910
551
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):
DRSFA, LLC
[e-mail]
Name
E-mail Address
3000 RDU Center Dr.
Suite 202
Current Mailing Address
Current Street Address
Morrisville NC
27560
City State
Zip City State Zip
Telephone [phone]
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-.
Jay Lewis [e-mail]
Name E-mail Address
3000 RDU Center Dr. Suite 202
Current Mailing Address Current Street Address
Morrisville NC 27560
City
State Zip
Telephone[phone]
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
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.
Paul Yeager Authorized 8gent
Type or print name Title or Authority
q 1 ao�al
Signature Date
6 a Notary Public of the County of . �dp
State of �Ie hereby certify that -i�l.� �. � . YCl�1i mcL 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 20day ofjEf�[—mF�; 20-7)
KIMBE LY A. SYCAL.IK
J� . I Notary Public otary
"=1 0 State of Maryland
y pilBL1G
ion a, a, . Frederick County My commission expires �Ua
My commission exp. October 21, 2023