NCC220222_FRO Submitted_20220126

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Environment and Natural Resources. (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: Cedar Creek Truck Stop
2. Location of land -disturbing activity: County: Cumberland City or Township: Fayetteville
Highway/Street Cedar Creek Road Latitude: 35° 2'19.54"N Longitude: 78°50'53.46"
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.80 Ac.
6. Amount of fee enclosed: $260.00. The Express Permitting application fee is a dual charge. The
normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No: Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Vishnu Patel E-mail Address: earth petroa-gmail.com
Telephone
Cell #: 910-391-5959 Fax #:
9. Landowner(s) of Record (attach accompanied page to list additional owners):
3 Star Fayetteville, LLC
Name
P.O. Box 220
Current Mailing Address
Wade, NC 28395
City State
910-391-5959
Telephone Fax Number
Same as Mailing Address
Current Street Address
Zip City
State
10. Deed Book No.10994 Page No.7889 Provide a copy of the most current deed.
Part B.
Zip
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):
3 Star Fayetteville, NC earth petroa-gmail.com
Name E-mail Address
P.O. Box 220 Same as Mailing Address
Current Mailing Address Current Street Address

Wade, INC 28395
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:
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:
Name of Manager
Current Mailing Address
City
Telephone:
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number:
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other consultant
who can assist in providing any necessary information regarding the plan and its preparation:
Paramounte Engineering, Inc. bsmith(o)paramounte-eng.com
Engineering Firm or other consultant E-mail Address
Branch Smith 910-791-6707
Individual contact person (type or print) Telephone 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.
SEE SEPARATE SIGNATURE PAGE
Type or print name Title or Authority
Signature
Date
I, , a Notary Public of the County of
State of North Carolina, hereby certify that
this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of
Seal
20
Notary
appeared personally before me
My commission expires

City State Zip
Telephone:
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.
Vishnu
Patel Member/Manager
Type or print name Title or Authority
&W Ds5 117]2-02—j
Signature
Date
q� & C a Notary Public of the County of
i/ L 1 '�
State of North Carolina, hereby certify that S 12U appeared
personalty before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this ` ( day of 20
MIREYA CANTOR
Notary Public
Harnett Co.. North Carolina
' "v Commission Expires Oct. 12, 2025
Seal
expires
L�
otary
My
commission