NCC240478_FRO Submitted_20240220

11:WI 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
NORTH cnaOi.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 SPCA OF WAKE COUNTY EXPANSION
2. Location of land-disturbing activity: Jurisdiction GARNER (Wake Co. or Municipality)
Highway/Street 200 PETFINDER LANE Latitude 35.727579 Longitude -78.662430
3. Approximate date land-disturbing activity will commence: 02/2023
4. Type of development (residential, commercial, industrial, institutional, etc.): Commerical
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 8.98 Acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Neil Harris E-mail Address [e-mail]
Telephone N/A Cell # [phone] Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
SPCA OF WAKE COUNTY, INC. [phone] [e-mail]
Name(s) Telephone Fax or E-mail address
200 PETFINDER LANE 200 PETFINDER LANE
Current Mailing Address Current Street Address
RALEIGH NC 27603 RALEIGH NC 27603
City State Zip City State Zip
8. Deed Book No. 008715 Page No. 01137 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):
SPCA OF WAKE COUNTY, INC. [e-mail]
Name E-mail Address
200 PETFINDER LANE 200 PETFINDER LANE
Current Mailing Address Current Street Address
RALEIGH NC 27603 RALEIGH NC 27603
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 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:
Richard Nordan -Wallace&Nordan,LLP [e-mail]
Name of Registered Agent E-mail Address
3737 Glenwood Ave.,Ste.260
Current Mailing Address Current Street Address
Raleigh,NC 27612
City State Zip City State Zip
Telephone [phone] 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.
Kim Janzen President/CEO
Type r rint name Title\ Aut ority
\\, d 2-02-3
Signat e Date
Neil Bray Harris , a Notary Public of the County of Wake
State of North Carolina, hereby certify that Kim Janzen appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my ttt in9tarial seal, this V' day of IOVGw 0
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