NCC242588_FRO Submitted_20240826

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation
Unified control plan have been completed and approved by Wake County Department of
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name MORRISVILLE GURUDWARA
2. Location of land-FRANnI&acts UiCHrURCH MORRISVILLE (Wake Co. or Municipality)
Highway/Street SR STRFFT Latitude 35 821821 Longitude -78.825971
3. Approximate date land-disturbing activity will commence: FEBRUARY 2024
4. Type of development(residential, commercial, industrial, institutional, etc.): INSTITUTIONAL
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3.5
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name TODD RANKINE E-mail Address [e-mail]
Telephone Cell# [phone] Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
TRIANGLE SIKH GURUDWARA, INC [phone] MCheema54 crgmail.com
Name(s) Telephone Fax or E-mail address
123 GRATIOT DRIVE 303 FRANKLIN UPCURCH SR STREET
Current Mailing Address Current Street Address
MORRISVILLE, NC 27560 -SAME-
City State Zip City State Zip
8. Deed Book No. 16169 Page No. 0861-0863 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
TRIANGLE SIKH GURUDWARA, INC MCheema54 a,,gmail.com
Name E-mail Address
123 GRATIOT DRIVE 303 FRANKLIN UPCURCH SR STREET
Current Mailing Address Current Street Address
MORRISVILLE, NC 27560 -SAME-
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
MANJIT CHEEMA [e-mail]
Name of Registered Agent E-mail Address
123 GRATIOT DRIVE 303 FRANKLIN UPCURCH SR STREET
Current Mailing Address Current Street Address
MORRISVILLE, NC 27560 -SAME-
City State Zip City State Zip
Telephone [phone] 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.
REGISTERED AGENT
MANJIT CHEEMA TRIANGLE SIKH GURUDWARA. INC.
Type or print n me Title or Authority
dt as - II
Signature J Date
I, ItOI)n1S iv c /V , a Notary Public of the County of
State of North Carolina, hereby certify that Alan\r t;I 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 t' t day of Ma , 207- 1
S`ltiiPiPd! N .L- C —.
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Notary
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