NCC222763_FRO Submitted_20220803

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 NIA in the blank.)
Part A.
1. Project Name Champs Convenience Store
2. Location of land -disturbing activity: County Harnett City or Township Hectors Creek Twsp.
US Hw 401 35.5112-78.8134
Highway/Street Latitude{decima] degrees) Longltilde(deamal degrees
3. Approximate date land -disturbing activity will commence: AS soon as possible
4. Purpose of development (residential, commercial, Industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.18
6. Amount of fee enclosed: $ 500.00 . 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 ❑ Enclosed x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ankit Patel E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jay Ambe Shakti, LLC 910-988-6049
Name Phone: Office # Mobile #
2100 Weaver Forest Way Same
Current Mailing Address Current Street Address
Morrisville N.C. 27560 Same
City State Zip City State Zip
10. Deed Book No. 401 1 Page No. 326 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).
Jay Ambe Shakti, LLC
Company Name
2100 Weaver Forest Way
[e-mail]
E-mail Address
Same
Current Mailing Address Current Street Address
Morrisville N.C. 27560 Same
City State Zip
Phone: Office #
City State Zip
Mobile # [phone]
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:
Kamleshkumar C Patel
Name of Registered Agent
401 Burlwood Court
Current Mailing Address
Fayetteville N.C. 28303
City State Zip
[e-mail]
E-mail Address
Same
Current Street Address
Same
City
Phone: Office # Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
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.
Ankit K Patel
Type or print name
Signature
Member
Title or Authority
C; [ 13 1 1312- z
Date
I e a Notary Public of the County of YK69e �r
State of North Carolina, hereby certify that An k t l ff A16W 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 13tk day of Jacvc.e , 20 22_
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