NCC223161_FRO Submitted_20220929

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
NORTH C;AROLINA 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 Mornington Estates Phase 4a - lot by lot
2. Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street Rock Service Station rd Latitude 35.6090 Longitude -78.6748
3. Approximate date land -disturbing activity will commence: September 01, 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): 4.99
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael Stewart E-mail Address [e-mail]
Telephone [phone] Cell # Fax # [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
6030 Rock Service Station Road LLC 516-426-8719
Name(s)
950 Clifton Ave.
Current Mailing Address
Telephone
Current Street Address
[e-mail]
Fax or E-mail address
Clifton NJ 07013
City State Zip City State Zip
8. Deed Book No. 2022 Page No. 01206 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):
6030 ROCK SERVICE STATION LLC
Name
950 Clifton ave
Current Mailing Address
Clifton NJ
City State
Telephone [phone]
E-mail Address
Current Street Address
07013
Zip City State
Fax Number
Zip

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:
Donald Denihan
Name
104 Darmouth Rd Apt. 630
Current Mailing Address
Raleigh nc 27609
City State Zip
[e-mail]
E-mail Address
104 Darmouth Rd Apt. 630
Current Street Address
Raleigh nc 27609
City
Telephone [phone] 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
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.
, rf Lk-` U IJ .) Lfi____
ype print name Title or /Authority
/Z�2Z
,-Signarure Date
-----------------------------------------------------------------------------------------------------------------------------------
I, _ jI6-Ai r, JJ Ay(A V0 , a Notary Public of the County of �v cam,
State of North Carolina, hereby certify that &P-) a_� cL ,cL , 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 net day of Ck.kcc_
H 1 Dq����
i
NCYAPO*
PUBLIC►
/!111 0
CvLe��� 0� lip tjCj� H, -0Ay/S
Notary
My commission expires '4a' S o S