NCC230414_FRO Submitted_20230214

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity on one or more acres as covered by Chapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed
and approved by the City of Charlotte. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion and Sedimentation
Ordinance. If the financially responsible party is out of State, a North Carolina agent must be assigned. All relevant
items on this form must be filled out accurately and completely
Please Type or Print
PART A
L Project name: Take 5 Car Wash
2. Address of land —disturbing activity:5311 N Tryon St. Charlotte NC 28213
3. Approximate date land -disturbing activity will commence: February 20 2023
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
5. Total acreage of land to be disturbed or uncovered: 1.33
6. List total site acreage: 1.25
7. Landowners of Record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firm(s) financially responsible as listed in Part B, item 1, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: Boing US Holdco, Inc.
Address:400 South Church St. Suite 700
Charlotte, NC 28202
Telephone: [phone]
(Area Code)
Email Address: PropertyManagem
Name:
Address:
Telephone:
(Area Code)
Email Address:
rivenbrands.com
Fax:
(Area Code)
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 37780
Page 231-237
Book Page
Book Page
Book Page
Page I

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity (Note: If the financially responsible
person(s) or frrni(s) has an oast -of -slate address, a North Carolina agent must be designated in item 2 helou):
Person or Firm: Boing US Holdco, Inc.
Address: 400 South Church St. Suite 700
Charlotte. NC 28202
Telephone: [phone] Fax:
(Area Code)
Email Address: [e-mail]
(Area Code)
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent:
Person or Firm:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual or by an
officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible company or entity, if not an individual.)
Boing US Holdco, Inc. By: Anthony Winchester,
Vice President -Legal. Real Estate Vice President - Legal, Real Estate
Printed Name
Title
January 24, 2023
Date
I, C 6�q S L M . C el— fA PSC-LL a Notary Public of the County
of Mecklenburg State of' North Carolina hereby
certify that Anthony Winchester personally
appeared before me this day and under oath acknowledge that this form ivas executed by him/her,
Witness my hand a)
Notary Signature:
Xly Commission expires: / —(o — LL) L
a
CAMPBELL PUBLIC.rg Countyarolina
charlottenc-gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
"1'e lephone: 704/336-6692
http://charlottene.gov/develoonientcenter
Rev. 09/2021 Page 2