NCC221757_FRO Submitted_20220506

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 NIA in the blank.)
Part A. PRIME EXPRESS KANNAPOLIS GATEWAY
1. Project Name
2. Location of land -disturbing activity: CountyCABARRUS City or Township KANNAPOLIS
Highway/Street R.L. KETCHIE BLVD. Latitude 35.438522 Longitude-80.678140
3. Approximate date land -disturbing activity will commence: NOVEMBER, 1 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):COMMERCIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8'5 AC.
6. Amount of fee enclosed: $ 585.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameSHAILESH PANARA
E-mail Addressuniversal( lublstores.com
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners) --
CITY OF KANNAPOLIS
704-920-4300
Name
Telephone Fax Number
401 LAUREATE WAY
SAME
Current Mailing Address
Current Street Address
KANNAPOLIS, NC 28081
SAME
City State Zip
City State Zip
10. Deed Book No. 14295 Page No. 0001 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.
VSP BUSINESS LLC
[e-mail]
Name
E-mail Address
1534 COPPERPLATE ROAD
SAME
Current Mailing Address
Current Street Address
CHARLOTTE NC 28262
SAME
City State Zip
City State Zip
Telephone [phone]
Fax Number 704-784-3332

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
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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:
VSP BUSINESS LLC
Name of Registered Agent
1534 COPPERPLATE ROAD
Current Mailing Address
CHARLOTTE NC 28262
City
Telephone
State Zip
980.722.3751
[e-mail]
E-mail Address
SAME
Current Street Address
SAME
City State Zip
Fax Number 704 . 784 . 3332
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.
SHAILESH PANARA
Type or print name
er, C�.rZvj
Signature
(A711(iC -�_
Title or Authority
0 -
Date
1, — 1`0 loG? Id L� f , a Notary Public of the County of C a �)a rl"yS
State of North Carolina, hereby certify that S� h 01 ) . 'sh Fa %i Gt rit appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this ".ol day of 20 l
AMANDA MOUNTS \ "
Notary Public - North Carolina Notary
owtus County
My Commission Expires Dec 13. 2025
My commission expires