NCC230334_FRO Submitted_20230207

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 Name Auto Finance & Car Care Center
2. Location of land -disturbing activity: County Union City or Towns hip_Vance Twsp._
Highway/Street Union Beltway Rd. Latitude . Longitude
3. Approximate date land -disturbing activity will commence: 11/15/20
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Commercial_
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_4.98 Ac.
6. Amount of fee enclosed: $_325.00 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).
7. Has an erosion and sediment control plan been filed? Yes_X No Enclosed_X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name —Dennis Norwood E-mail [e-mail]_
Telephone_704-553-0834 Cell # _704-576-1869 Fax # _704-553-2096_
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_DMK Holdings LLC. 980-297-1200
Name Telephone Fax Number
_12719 Lindrick Ln. _12719 Lindrick
Current Mailing Address Current Street Address
_Charlotte NC 28277 _Charlotte NC 28277
City State Zip City State Zip
10. Deed Book No._7533 Page No._0754 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.
_DMK Holdings LLC.
Name
_12719 Lindrick Ln.
Current Mailing Address
_Charlotte NC 28277
City State Zip
[e-mail]_
E-mail Address
_12719 Lindrick Ln._
Current Street Address
_Charlotte NC 28277_
City State Zip

Telephone_980-297-1200 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
E-mail 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:
_McGrath and Spielberger _PLLC _
Name of Registered Agent
_12719 Lindrick Ln.
Current Mailing Address
_Charlotte NC 28277
City State: Zip
Telephone_980-297-1200 _
[e-mail]
E-mail Address
_12719 Lindrick Ln.
Current Street Address
_Charlotte NC 28277_
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.
_David R. Algood
Type or print,
Signatur
_CEO
Title or Authority
Date
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pp------------------------- =------------------------- =------------------------------------------------
a Notary Public of the County of U t
State of North Carolina, hereby certify that t D i ' C) �> appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand
NOF,�R 4's
� �eLIC
Seal s'j'� �m 2 ��•''
is__761 day of 202
Notary
My commission expires ( -7 20Z?-