NCC216445_FRO Submitted_20211117

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. 1. Project NameMorrisville Square Offices
2. Location of land -disturbing activity: County Wa ke City or Township Morrisville
Highway/StreetMorrissville Square way Latitude35.818890 Longitude-78.828400
3. Approximate date land -disturbing activity will commence: 11-17-2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.33
6. Amount of fee enclosed: $1 30 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
Has an erosion and sediment control plan been filed? YesyeS No Enclosedyes
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameHemant Sura
Telephone [phone]
E-mail Address hsura@greentc. com
Cell # 919-608-2412 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
GreenTech Investment LLC 919-608-2412
Name
1155 Kildaire Farm Road, St. 206
Current Mailing Address
Carv, NC 27511
Telephone
Fax Number
1155 Kildaire Farm Road, St. 206
Current Street Address
Cary, NC 27511
City State Zip City
10. Deed Book No. 1 6363 Page No. 1 501
State
Zip
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
GreenTech Investment LLC [e-mail]
Name E-mail Address
1155 Kildaire Farm Road, St. 206 1155 Kildaire Farm Road, St. 206
Current Mailing Address
Cary, NC 27511
City State Zip
Telephone[phone]
Current Street Address
Cary, NC 27511
City State Zip
Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City State Zip
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Hemant Sura
Type or print name
Signature
Member Manager
Title or Authority
11-15-21
Date
1, C_,_�N 5 , a Notary Public of the County of -2_
State of North Carolina, hereby certify that ro: appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notqg4gj,seal, this _day of o , 20 _
GO , S
p'f A R y • — �— -
Notary
Seal:
pUgO My commission expires .