NCC223946_FRO Submitted_20221213

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 Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name__ Serenity Subdivision Phase 2A & 2B
2. Location of land -disturbing activity: County Harnett City or Township Hector's Creek
Piney Grove Rawls Road 35.544427'-78828212°
Highway/Street Latltude(decimal degrees) Longitude(decimal degrees)
3. Aprroximate date land -disturbing activity will commence;_ Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): ReSldentiai
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.99 AC
6. Amount of fee enclosed: $1,100 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed © No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ben Taylor, VP Development E-mail Address [e-mail]
Phone: Office # [phone] Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Greenfield - Serenity, LLC 919-830-2670
Name
8601 Six Forks Road, Suite 270
Current Mailing Address
Raleigh NC 27615
City State
10. Deed Book No. 371 1
Phone: Office # Mobile #
8601 Six Forks Road, Suite 270
Current Street Address
Raleigh
Zip City
Page No. 0808
NC 27615
State Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Greenfield - Serenity, LLC
Company Name
8601 Six Forks Road, Suite 270
Current Mailing Address
Raleigh NC 27615
City State Zip
Phone: Office # 919-830-2670
[e-mail]
E-mail Address
8601 Six Forks Road, Suite 270
Current Street Address
Raleigh NC
City State
Mobile #
27615
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landownPr's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Yang Song
Name of Registered Agent
8601 Six Forks Road, Suite 270
Current Mailing Address
Raleigh NC 27615
City State Zip
Phone: Office #
[e-mail]
E-mail Address
8601 Six Forks Road, Suite 270
Current Street Address
Raleigh NC 27615
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected, information should there be any change in the information provided herein.
N 9N
Type or print name
sign e
I, V.lIt q. 45-11rotm
KKW h(4 �
Title or Authority
Date
,a Notary Public of the County of W iR er
State of North Carolina, hereby certify that � pwG g ajj(� _appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this (, h day of �ipr� I , 20�-1
Not ry
My commission expires`5�,�,r,� ►'►_ 2oa3
KRISTLE H. OSTEEN
NOTARY PUBLIC
WAKE COUNTY, N.C.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 3 of Record:
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 4 of Record:
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. — Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address
City
Phone: Office #
Company 3 Name
Current Mailing Address
City
Phone: Office #
Current Street Address
State Zip City
Mobile #
State
E-mail Address
Current Street Address
State Zip City State
Mobile #
Zip
Zip
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #