NCC242256_FRO Submitted_20240724

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.)
P1.art A.Project Name Rocket Wash
2. Location of land-disturbing activity: CountyHarnett City or TownshipDUnn
Highway/Street Cumberland St Latitude 35.32367906042551 Longitude-78.64141011739824
3. Approximate date land-disturbing activity will commence:8/1/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas).1'25
6. Amount of fee enclosed: $ 125 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? YesX No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Nick Nicholson E-mail Address [e-mail]
Telephone [phone] Cell# 919-943-8123 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Sunshine Express Carwash LLC 919-427-8965
Name Telephone Fax Number
PO Box 176 228 Airport Road
Current Mailing Address Current Street Address
Buies Creek NC 27506 Erwin NC 28339
City State Zip City State Zip
10. Deed Book No.04226 Page No.2044 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 pat ty.
Rocket Wash Raeford, Inc [e-mail]
Name E-mail Address
3723 Benson Drive 3723 Benson Drive
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip 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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
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 Nicholson . CFO
Type o pri na Title or Authority
7/23/2024
Signature Date
I, ti5 idI efrFl A Ak a Notary Public of the County of
State of North Carolina, hereby certify that Nick Nicholson appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. n
Witness my hand and notarial seal, this �2-‘✓ C.day of � � �,L,(:l.' , 20 a DENISE W.JOHNSON t
NOTAEMPUBLIC I
r7�
WAKE COUNTY .C. , My commission expires
My Commission Expires 5 1 acG .