NCC230525_FRO Submitted_20230224

CW_ WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
0=7 SEDIMENTATION POLLUTION CONTROL ACT
��No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NOR I'fI ('ARUI INA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name Take 5 Car Wash
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Fayetteville Rd. _ Latitude 35.722588 Longitude-78.653296
3. Approximate date land -disturbing activity will commence: 10f 112022
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1.04 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Rebecca McAllister
Telephone [phone] Cell #
E-mail Address [e-mail]
Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Jing Hwa, Inc. - Derek Chan 917-841-8111
Name(s) Telephone
16137 91 st Street 16137 91 st Street
Current Mailing Address Current Street Address
Howard Beach, NY 11414 Howard Beach, NY 11414
City State Zip City State
8. Deed Book No. 017526
Part B.
Page No. 00284
Fax or E-mail address
Zip
Provide a copy of the most current deed.
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. Include requested information):
Boing US Holdco, Inc. (dba "Take 5 Car Wash") [e-mail]
Name E-mail Address
440 South Church Street, Suite 700 440 South Church Street, Suite 700
Current Mailing Address Current Street Address
Charlotte, NC 28202
City State
Charlotte, NC 28202
Zip City
Telephone [phone] Fax Number
State
Zip

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit.
Corporation Service Company
Name of Registered Agent
2626 Glenwood Ave Ste 550
Current Mailing Address
Raleigh, NC 27608
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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:
Corporation Service Company
Name of Registered Agent
2626 Glenwood Ave Ste 550
Current Mailing Address
Raleigh, NC 27608
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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.
Scott O'Melia Secretary
Type or grin '' ame (,1 Title or Auth rity
Signature Date
I,&e-I-do ,I �ry" - A:L 1-15. , a Notary Public of the County of —An(,C' LL�'_j'1���C
State of North Carolina, hereby certify that _aX c_' L\'�]� i 1 C\ 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 3 day of 20
BRENDA GALLMAN-AR71S
Notary Public, North Carolina NOtg J
Mec�ggpurg County y `
My Commission Expires October20,2024 My commission expires

{Date)
Re: Take 5 Car Wash — Redevelopment
To whom it may concern:
This letter provides permission to Boing US Holdco, Inc dba Take 5 Car Wash. to seek and obtain plan
approval to perform grading and%r sitework associated with the above referenced project. By signing
below the undersigned parties agree to the following:
DESCRIPTION of location and purpose of work
Parcel #1701-28-9110 located at 4202 Fayetteville Road, Raleigh, NC 27603 and being 0.962 +/- acres in
size. The purpose of this work will be to facilitate the redevelopment with a single bay automated carwash
and subsequ t parking loth 'th vacuum stalls.
Signature of property owner or authorized representative
ling Hwa, fnc. — Derek Chan
Printed name of property owner, company group, corporation, or individual, and authorized
representative.
16137 915L Street, Howard Beach, NY 11414
Mailing address of owner or party represented above
a Notary Public of the County of
State of hereby certify that LaLi � appeared
personally before mty and being duly sworn acknowledged that the above form was executed by
Kim.
Witness my hand and notarial seal, this
lDay of
otary Seal
My commission expires O a- '7 2
LESLIE TORRES
Notary Public - State of New Yo; i,
No. 01T06319258
Qualified in Nassau County
My Commission Expires Feb. 17, 25_,Z3