HomeMy WebLinkAboutNCC240770_FRO Submitted_20240318 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 NameSam's Xpress Car Wash
2. Location of land-disturbing activity: CountyAlamance City or Township Burlington
107 Chapel Hill Road 36.081911N -79.461567W
Highway/Street LatltUde(decimal degrees) LongitUde(decimal degrees)
3. Approximate date land-disturbing activity will commence:November 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.8
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 0 Enclosed ❑x No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameAnthony Warren E-mail Addressawarren@Samsxpress.com
Phone: Office# 704-648-4703 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
SXCW Properties II, LLC 704-648-4703
Name Phone: Office# Mobile#
7935 Council Place, Suite 200 7e135 ��a«
Current Mailing Address Current Street Address
Matthews, NC 28105 << 14 /1/4
City State Zip City State Zip
10. Deed Book No.3659 Page No.814 Provide a copy of the most current deed.
Part B.
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).
SXCW Properties It, LLC awarren@samsxpress.com
Company Name E-mail Address
7935 Council Place, Suite 200 7935 Council Place
Current Mailing Address Current Street Address
Matthews, NC 28105 Matthews, NC 28105
City State Zip City State Zip
Phone: Office# 704-648-4703 Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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 State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(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
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Anthony W en Director of Business Development
Type or • Title or Authority
/11-2-
• ure Date
I, E..C .iors rk•,)-1 , a Notary Public of the County of LtY1►,A
State of North Carolina, hereby certify that . xciH� Wc, -ref , appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 3i day ofj,.,�� , 20 Z 3
Notary
My commission expires '+29- ZDZ/2
UNANIMOUS WRITTEN CONSENT AND RESOLUTIONS
OF THE SOLE MEMBER OF
LLCs
WHEREAS, the undersigned, Sami I. Nafisi, certifies that he, individually, is the sole
Manager of, among others, each limited liability company set forth on Schedule 1 attached
hereto (as Schedule 1 may be amended from time to time, collectively, the "LLCs" and each a
"LLC") and each LLC is a North Carolina limited liability company, having its principal place of
business at 7935 Council Place, Suite 200, Matthews, North Carolina; and
WHEREAS, the undersigned hereby consents in writing, pursuant to the Limited
Liability Company Act of the State of North Carolina (the "Act"), and adopts the following
resolution of the LLCs, all pursuant to the laws of the State of North Carolina; and
WHEREAS, the undersigned, in adopting the resolutions set forth below by signing his
consent hereto (this "Consent"), hereby confirms, ratifies and approves the acts stated in this
Consent and directs that this Consent be filed with the minutes and proceedings of the LLCs.
Without otherwise limiting the generality of the foregoing, this Consent shall be effective, as of
the date set forth below, as if adopted by the vote of the undersigned at a meeting called pursuant
to notice, all as required by the Operating Agreement of the LLCs, at which meeting the
undersigned was present in person.
NOW WHEREFORE, by executing this Consent, as indicated below, the undersigned
agrees to, consents to and approves the following:
RESOLVED, that Anthony Warren as Development Manager of Sam's Xpress Car
Wash shall have a limited right, power and authority to execute, sign, verify, acknowledge,
deliver, and accept all construction and development documents and applications submitted to
and/or required by any governmental authority, including but not limited to documents relating
to permitting, building permit applications, site plan approval documents, surveys and plats,
storm water mitigation, zoning applications, variance requests, utility applications, tap fees,
applications for driveways and encroachments, erosion control, grading permit applications and
environmental questionnaires on behalf of the LLCs; and
FURTHER RESOLVED, the undersigned further certifies that the LLCs' Articles of
Organization and Operating Agreement remain in full force and effect and nothing has occurred
to limit the LLCs' ability to enter into or complete the actions contemplated. This Consent is
executed by the sole Manager of the LLCs for the purposes contemplated.
[Signature Page Follows]
IN WITNESS WHEREOF, the undersigned, as the sole Manager of the LLCs hereby
executed this Unanimous Written Consent and Resolutions o the Sole Member of LLCs as of the
date written below.
Sami I. Nafisi, as Manager of each LLC
Dated: l 26 ( � 2
SCHEDULE 1 TO UNANIMOUS WRITTEN CONSENT AND RESOLUTIONS
OF THE SOLE MEMBER OF LLCs
LIST OF LLCS SAMI I. NAFISI IS SOLE MANAGER OF
AND FOR WHICH ANTHONY WARREN AS DEVELOPMENT MANAGER OF
SAM'S )(PRESS CAR WASH
1. Sam's Xpress Car Wash, LLC
2. Sam's Xpress Car Wash II, LLC
3. SXCW Properties, LLC
4. SXCW Pr perties II,LLC
Sami I.Nafisi, as Manager of each LLC
Dated: U (2 & 12 G.Z
X{C V kn County,North Carolina
I certify that the following person(s)personally appeared before me this day, each
acknowledging to me that he or she signed the foregoing document:
Sami I. Nafisi .
Name(s) ofprincipal(s)
Date: 18 NC NO 2 I (Official Seal)
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