NCC223989_FRO Submitted_20221220

ADW
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 Henderson County Site Development Department. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Sign the original form in BLUE INK.
Part A. To Do Car Wash 11 INC
1. Project Name p g
2. Location of land -disturbing activity: County Henderson City Fletcher
Highway/Street Hwy 25 Latitude 35.443982 Longitude-82.506266
Property Identification Number(s) PIN's 9653-54-9966
3. Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 .2
6. Amount of fee enclosed: $ 800 . The application fee of $300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac = $2,900.00).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Rich Bartels E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Anaqnostopoulos II LLC 828-273-3389
Name Telephone
7 Brookside RD 7 Brookside RD
Current Mailing Address Current Street Address
Asheville NC 28 Asheville NC 28!
City State Zip City State Zip
10. Deed Book No. Page No. 344 Provide a copy of the most current deed.
Part B. &z ! �5
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.
Anagnostopoulos II LLC [e-mail]
Name E-mail Address
7 Brookside Rd 7 Brookside Rd
Current Mailing Address
Asheville NC 28
City State Zip
Current Street Address
Asheville NC M
City State
Zip
Telephone [phone] 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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.
Nick Anagnostopoulos
Typ or pri n name
17 (' ,'
Signature
Owner/Manager
Title or Authority
1\160 . i � • 2.r)Z2_
Date
I, 6&_,c4 s , a Notary Public of the County of '/
State of _ IV Ct . , hereby certify that u, r' ,&aA pa drp-W ks
appeared personally before me this day and being duly swornJacknoMedged that the above
form was executed by him.
Witness m; hin�d+'otarial seal, this 1day of 1rlLVew� 20
�p�AR1 Not
S%al ECG Z
Myl mmission expires 0'7- (7L1 --J-a