NCC231552_FRO Submitted_20230523

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WAKECounty 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
N ,R H r Aa 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 FSC II, LLC Knightdale Plant Expansion
2. Location of land-disturbing activity: Jurisdiction Knightdale (Wake Co. or Municipality)
Highway/Street Old Montague Lane Latitude 35.8023° Longitude -78.5075°
3. Approximate date land-disturbing activity will commence: June 2022
4. Type of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 8.0
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Andrew Norton E-mail Address [e-mail]
Telephone - Cell # 919-818-1264 Fax# [phone]
7. Landowner(s)of Record (attach accompanied page to list additional owners):
FSC II, LLC 69 [e-mail]
Name(s) Telephone Fax or E-mail address
701 Corporate Center Dr.Suite 101 701 Corporate Center Dr.Suite 101
Current Mailing Address Current Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip
8. Deed Book No. 18554 Page No. 1637 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): _
FSC II, LLC [e-mail]
Name E-mail Address
p t nt p 701 Corporate Center Dr.Suite 101
C7iJrr�r�� NItrrY4 Hefi�7'r2 Bite 101 Current Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip
Telephone [phone] Fax Number 919-582-3645

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 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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Andrew Norton Vice President-Legal
Type or print name Title or Authority
g ature Date
I, CA 5. L& %� .i $ , a Notary Public of the County of Walk-2.
State of North Carolina, hereby certify that NvNAreu.) 1. I Jo( 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 21,o day of 9Ak , 20.• ZZ..
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