NCC230647_FRO Submitted_20230310

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' - FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity that disturbs one or more acres as covered by the Town of
Clayton Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Clayton. Lots smaller than one
acre that are part of a larger plan of development are also subject to Town of Clayton Soil Erosion and
Sedimentation Control Ordinance and are required to complete this form. (Please type or print and, if the
question is not applicable or the e-mail andlor fax information unavailable, place NIA in the blank.)
Part A.
I. Project Name Flex Warehouse S Tech
2. Location of land -disturbing activity: County JOHNSTON t� City or Township CLAYTON
Highway/StreetS Tech Park Ln Latitude35.61 378 Longitude-78.42478
1 Approximate date land -disturbing activity wi€1 commence: 1 111 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areasy 4•3
6. Has an erosion and sediment control plan been filed? Yes
i7
No Enclosed ✓
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NamePremArmarnathan E-mail Address [e-mail]
Telephone [phone]
Cell #
Fax #
S. Landowner(s) of Record (attach accompanied page to list additional owners):
Tech Park Development, LLC 646-250-7736
Name
2000 Bearcat Way, Suite 102
Current Mailing Address
Morrisville NC 27560
city State
9. Deed Book No. 061 21
Part B.
Telephone Fax Number
2000 Bearcat Way, Suite 102
Current Street Address
Morrisville NC 27560
Zip City
Page No. 6146
State
Zip
Provide a copy of the most current deed.
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.
Tech Park Development, LLC
Name
2000 Bearcat Way, Suite 102
Current Mailing Address
Morrisville NC 27560
city state Zip
Telephone [phone]
prem Low apaventures.com
E-mail Address
2000 Bearcat Way, Suite 102
Current Street Address
Morrisville NC 27560
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
C ity,
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.
Prem Armarnathan
Type or print name
c.4.
Signatur '
President
Title or Authority
0 2— 2 ' Y
Date
a Notary Public of the County of
State of North Carolina, hereby certify that P,( p fy-� _ 6 (A Mrk c\ 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 _Z _� day of V::>runcu , 20 2 �
I — -
JANETT AVILES
(Votary Public Notary
0�I Wake Co., North Caroiirta
Cbmmission Expires June 21, 2027 My commission expires 0 Z1 Z �Z