NCC223195_FRO Submitted_20220912

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.)
Part A. BOJANGLES
1. Project Name
2. Location of land -disturbing activity: CountyCABARRUS City or Township KANNAPOLIS
Highway/Street LANE STREET Latitude35.4998 Longitude-80.5694
3. Approximate date land -disturbing activity will commence: April 1 , 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.30
6. Amount of fee enclosed: $ 200 . 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? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Claude Clark E-mail Address [e-mail]
Telephone
cell # 980-721-9166 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Quicktrip Corporation
918-994-3558
Name
Telephone Fax Number
5725 Foxridge Dr
1120 N. Industrial Drive
Current Mailing Address
Current Street Address
Mission KS 66202 Euless TX 76039
City State
Zip City State Zip
10. Deed Book No. 09005
Page No. 354 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.
561 Lowcountry, LLC
[e-mail]
Name
E-mail Address
800 East Blvd, Suite 210
800 East Blvd, Ste 210
Current Mailing Address
Current Street Address
Charlotte NC
28203 Charlotte NC 28203
City State
Zip City State Zip
704-376-7484
Telephone
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
E-mail Address
Current Mailing 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 Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
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.
Henry Atkins
TyI'e' print name
Signature
Manager of TAG Ventures, LLC as manager of 561 Lowcountry, LLC
Title or Authority,
Date
I, �iC�. �.�(• �e rs �YY'►C'.( —,a Notary Public of the County of 1�i�CiL�t l'� �i2►� I
State of North Carolina, hereby certify that 4ery ( Ptk6rns appeared J
personally before me this day and being duly swofn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this r I ILK day of bI A&V , 20 `Z _
�-
Seal
My commission expires C� 10��C h ZfA �202.i�