NCC232869_FRO Submitted_20230922

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville(Title 9, Chapter 8)before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Greenville,
Engineering Department. (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 Fresenius Dialysis
2. Location of land-disturbing activity: County Pitt City or Township Greenville
Highway/Street WH Smith and Dickinson Ave. Latitude(decimal degrees)35.597703 Longitude(decimal degrees) -77.399305
3. Approximate date land-disturbing activity will commence: November 1, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.5 Acres
6. Amount of fee enclosed: $ 200.00 . The application fee of$100.00 per acre or portion
thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre
application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed X No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Nicholas Fitzgerald E-mail Address nicholas.fitzgerald(aarkconsultinggroup.com
Phone: Office# 252-565-1023 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Venture Partners I, LLC 252-355-7355
Name Phone: Office# Mobile#
PO Box 2575 2140 W. Arlington Blvd. Ste A
Current Mailing Address Current Street Address
Greenville NC 27836 Greenville NC 27834
City State Zip City State Zip
10. Deed Book No. 004326 Page No. 00038 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).
COP Greenville, LLC [e-mail]
Company Name E-mail Address
919 Conestoga Road, Building 3, Ste 211
Current Mailing Address Current Street Address
Bryn Mawr, PA 19010
City State Zip City State Zip
Phone: Office# Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner'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:
rnrporatinn 5ervirP nompany [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Avenue. Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608
City State Zip City State Zip
Phone: Office# 800-927-9800 Mobile# [phone]
Kate Melendez
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(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.
Michael Milone Member
Type or print name Title or Authority
7/13/2023
Signature Date
I, Elizabeth 011ero , a Notary Public of the County of Delaware
Commonwealth of Pennsylvania, hereby certify that Michael Milone 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 13th day of Jul 0 23
Notary i
My commission expires January 5, 2025
Commonwealth of Pennsylvania•Notary Seal
ELIZA6ET14 OLLERO•Notary Public
Delaware County
My Commission Expires January 5,2025
Commission Number 1379817