NCC223869_FRO Submitted_20221207

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 Phases 1 D, 1 E, 2C, 2D, 2E, 2F, 2G, 6A, 6B, 6C, 6D, 6E, 6F & 6G
2. Location of land -disturbing activity: County Harnett City or Township Hectors Creek
Serenity Walk Parkway 35.546841-78.835183
Highway/Street Latitude{decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 93 acres
6. Amount of fee enclosed: $$%300 . 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 ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ben Taylor
Phone: Office # 919-630-6641
E-mail Address btaylorQa greenfieldcommunities.com
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Greenfield Serenity, LLC
Name
8601 Six Forks Road, Ste 270
Phone: Office # Mobile #
8601 Six Forks Road, Ste 270
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
10. Deed Book No.371 1 Page No.0808 Provide a copy of the most current deed.

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, Ste 270
Current Mailing Address
Raleigh, NC 27615
City State Zip
Phone: Office# 919-630-6641
[e-mail]
E-mail Address
8601 Six Forks Road, Ste 270
Current Street Address
Raleigh, NC 27615
City State I Zip
"I"IfUNWIM
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners 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:
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Name of Registered Agent
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Current Mailing Address
2awtv% ls�C 2161E
City State Zip
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Current Street Address
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City State Zip
Phone: Office # Mobile# qtq43o-avip
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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
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
ofthe Certificate mfAssumed Name.
The above information iStrue and correct tOthe best ofmyknowledge 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 afforney-in-fact, or if not an individual, by an ofUcer, director, pGrtAer. or registered agent with
the authority to execute instruments for the Financially Responsible Party). | 80N]8 to provide
corrected information should there be any change inthe information provided herein.
Signature,-'�' Date
State OfNorth Carolina,
before me this day and being duly sworn acknowleaged that the above form was executed by him/her.
Witness nlyhand and notarial seal, this ayof 2
NOTARY PUBLIC Ncea'ry