NCC240745_FRO Submitted_20240315

"WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WADENo may e tty or r as ed t
Countyperson Unified Development initiatany land-dis Ordinance urbing ac beforeivit on this ne formomore and ac anes acceptablecover erosionbyheWake and
COUNTY rii---
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 N/A in the blank.)
Part A.
1. Project Name Wendell Falls Force Main Phases 1 B and 2
2. Location of land-disturbing activity: Jurisdiction Wake Co. (Wake Co. or Municipality)
Highway/Street Poole Rd(SR 1007) Latitude 35.74866 Longitude -78.46636
3. Approximate date land-disturbing activity will commence:
4. Type of development(residential, commercial, industrial, institutional, etc.)
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 7.78
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tanya Matzen E-mail Address [e-mail]
Telephone [phone] Cell# 919-521-2583 Fax#
7 Landowner(s) of Record (attach accompanied page to list additional owners)
See Attached
Name(s) Telephone Fax or E-mail address
Current Mailing Address Current Street Address
City State Zip City State Zip
8. Deed Book No. Page No. 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):
Nash Wendell Falls, LLC [e-mail]
Name E-mail Address
4020 Westchase Blvd, Suite 150 4020 Westchase Blvd, Suite 150
Current Mailing Address Current Street Address
Raleigh, NC 27607 Raleigh, NC 27607
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:
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:
Corporation Service Company
Name of Registered Agent E-mail Address
2626 Glenwood Avem Suite 550 2626 Glenwood Ave,Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
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.
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Type o print na Title or Authority
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Signature Date
I, 4'1YVlL1 L. I s....e J•-co, , a Notary Public of the County of (n,reu i
State of J North Carolina, hereby certify that TCt,LUQ t AOIi-ZLh 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 5 day of 1�cc, .p 4c cA' , 20 23
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