NCC231207_FRO Submitted_20230426

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 N/A in the blank.)
Part A.
1. Project Name Hwy 74 Development
2. Location of land-disturbing activity: County Union City or Township Indian Trail
W Hwy 74 35 03'48" 80 38'09"
Highway/Street Latitude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 10/15/2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.10
6. Amount of fee enclosed: $400 . 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
Stephen Knudsen E-mail Address [e-mail]
Phone: Office# 704-319-8346 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Indian Trail PSA, LLC 704-319-8346
Name Phone: Office# Mobile#
106 Foster Ave 106 Foster Ave
Current Mailing Address Current Street Address
Charlotte NC 28203 Charlotte NC 28203
City State Zip City State Zip
10. Deed Book No. 8442 Page No.0001 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).
Indian Trail PSA, LLC [e-mail]
Company Name E-mail Address
106 Foster Ave 106 Foster Ave
Current Mailing Address Current Street Address
Charlotte NC 28203 Charlotte NC 28203
City State Zip City State Zip
Phone: Office# 704-319-8346 Mobile#
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:
DBN Durban Management, LLC [e-mail]
Name of Registered Agent E-mail Address
106 Foster Ave 106 Foster Ave
Current Mailing Address Current Street Address
Charlotte NC 28203 Charlotte NC 28203
City State Zip City State Zip
Phone: Office# 704-319-8346 Mobile#
Stephen Knudsen
Name of Individual to Contact(if Registered Agent is a company)
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# 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.
Glen Cherry Principal / Vivia &v
Type or t name Title or Authority
9/26/22
Signature Date
I, D_ lQfrw2 -P0 d , a Notary Public of the County of MotectlevavdC
State of North Carolina, hereby certify that 6(e4 b• CUew1 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 ?/!) day of sop` 14�''� 20 Z2-
D. Ryland Pond
NOTARY PUBLIC Notary
M6 cklenburg County
North Carolina My commission expires 10 �I�' ZOZ
My Commission Expires October i4,2025

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Take 5 Carolinas Property Company, LLC 336-207-4985
Name Phone: Office# Mobile#
429 N Sharon Amity, Unit 7D 429 N Sharon Amity, Unit 7D
Current Mailing Address Current Street Address
Charlotte NC 28211 Charlotte NC 28211
City State Zip City State Zip
Deed Book No.8375 Page No. 171 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

FILED
UNION COUNTY, NC
CRYSTAL D. GILLIARD
REGISTER OF DEEDS
FILED Mar 31, 2022
AT 03:34 pm
BOOK 08442
START PAGE 0001
END PAGE 0003
INSTRUMENT# 12113
Prepared by: EXCISE TAX $1,362.00
Daniel R.Visalli,Esq.,Swindell&Visalli,PLLC JT
When recorded,return to Grantee
Excise Tax: $1,362.00
Tax Parcel No.: Portion of 07-069-102
Brief Description for Index:Lot 2,Plat Cabinet Q,File 463
STATE OF NORTH CAROLINA
NORTH CAROLINA
COUNTY OF UNION SPECIAL WARRANTY DEED
THIS NORTH CAROLINA SPECIAL WARRANTY DEED is made as of the ag`}"
day of March,2022 by
GRANTOR: TAKE 5 CAROLINAS PROPERTY COMPANY,LLC
a Delaware limited liability company
Grantor's Address: 429-D S. Sharon Amity Road
Charlotte,NC 28211
to
GRANTEE: INDIAN TRAIL PSA,LLC,
a North Carolina limited liability company
Grantee's Address: 106 Foster Avenue
Charlotte,NC 28203
For good and valuable consideration, the receipt and sufficiency of which are hereby
acknowledged, Grantor does grant, bargain, sell and convey unto Grantee, in fee simple,
all of Grantor's right, title and interest in and to that certain real property located in the
County of Union, State of North Carolina more particularly described as follows (the
"Land"):

BEING all of Lot 2 on that plan entitled"Final Plat of: Highway 74 Development
Subdivision Plat" prepared by R.B. Pharr& Associates, P.A. and recorded in Plat
Cabinet Q,File 463 in the Union County Public Registry.
TOGETHER with all buildings and improvements on the Land (jointly, the
"Improvements"), and all appurtenances, easements, rights of way, licenses, interests,
alleys, strips or gores of land located on or pertaining to the Land (the
"Appurtenances")(the Land, the Improvements, and the Appurtenances are collectively
referenced herein as the"Real Property").
The Real Property hereinabove described was acquired by Grantor by instrument
recorded in Book , Page 11-1 of the Union County Public Registry.
All or a portion of the Real Property herein conveyed does not include the primary
residence of a Grantor.
TO HAVE AND TO HOLD the-aforesaid-Land and-Improvements in-fee-simple,and all
privileges and appurtenances thereto belonging,to Grantee.
And=the-Grantor-covenants-with-the-Grantee,-that-Grantor-has-done nothing-to impair
such title as Grantor received, and Grantor will warrant and defend the title against the
lawful claims of all persons claiming by, under or through Grantor.
This conveyance is SUBJECT TO the following exceptions to title (the "Permitted
Exceptions"):
1. Taxes for the year 2022 and subsequent years, not yet due and payable.
2. Zoning Ordinances and other laws applicable to the Real Property;
3. Easements, covenants,restrictions and other matters appearing on the public
records which are applicable to the Real Property; and
4. Matters that would appear on a current survey of the Real Property.

IN WITNESS WHEREOF, Grantor, by authority duly given, has executed this
instrument as of the day and year first above written.
GRANTOR:
TAKE 5 CAROLINAS PROPERTY
COMPANY, LLC,a Delaware limited liability
company
By: Take 5 Carolinas,LLC, its Sole Member
By: 4N,.2e,.,24 e1..
William Mills,Manager
STATE OF NORTH CAROLINA
COUNTY OF MECKLENBURG
I certify that the following person(s) personally appeared before me this day, each
acknowledging to me that he or she voluntarily signed the foregoing document for the
purpose stated therein and in the capacity indicated: William Mills, Manager of Take 5
Carolinas, LLC, a Delaware limited liability company, the sole member of Take 5
Carolinas Property Company,LLC, a Delaware limited liability company.
•
Date: 3 Q 3—eta a
Printed or Typed Name:Do n 1 e• i P- • Vis 1
Notary Public
My commission expires: 2-13 - 2-`)L
[Official Stamp/Seal] o»`!""'�'"ua,,,,
NOTARy�'(-
MY
COMMISSION EXPIRES
` 2/13/2026 U k
A
UBL G ,c.
,,��"I, ,,URGCOI"��,.

BK 8375 PG 0171
FILED
UNION COUNTY, NC
CRYSTAL D.GILLIARD
REGISTER OF DEEDS
FILED Jan 18,2022
AT 11:36 am
BOOK 08375 •
START PAGE 0171
END PAGE 0174
INSTRUMENT# 02060
EXCISE TAX $2,350.00
PM
NORTH CAROLINA SPECIAL WARRANTY DEED
Excise Tax: $2,350,00
Parcel Identifier No.07069102
Verified by Union County on the_ day of ,2022
By:
Mail/Box to:Grantee
This instrument was prepared by:Alexander Rickfl,'LCC,1420 E.T�Street,Suite 100,Charlotte,
North Carolina 28204**No title search or opinion rendered by preparer
Brief description for the Index:5710 U.S.Hwy 74,Indian Trail,Union County,North Carolina
THIS DEED made this day of JanUAn ,2022,by and between:
GRANTOR GRANTEE
All Niakouei and spouse Zahra Valaie,a Take 5 Carolinas Property Company,LLC,
60%undivided interest as Tenant in Common a Delaware limited liability company
and
Mehdi N.Shirazl and spouse Laura Mailing Address:
Shiraz!,a 40%undivided interest as Tenant
In Common 429-D S.Sharon Amity Road
Charlotte,North Carolina 28211
Mailing Address:
5710 HWY 74 WEST
Indian Trial,NC 28079
$ I
The designation Grantor and Grantee as used herein shall include said parties, their heirs,
successors, and assigns, and shall include singular, plural, masculine, feminine or neuter as
required by context.
II
00274-022/00356063-1 I of 3

BK 8375 PG 0172
•
WITNESSETH,that the Grantor,for a valuable consideration paid by the Grantee,the receipt of
which is hereby acknowledged, has and by these presents does grant, bargain, sell and convey
unto the Grantee in fee simple,subject to the exceptions and reservations hereinafter provided,
all that certain lot or parcel of land situated in or near the City of Indian Trail,Union County, North
Carolina,and more particularly described as follows(the"Property"):
See Exhibit A
Together with all rights,easements and appurtenances thereto,
The property herein conveyed does not include the primary residence of a Grantor.
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances
thereto belonging to the Grantee in fee simple, subject to the exceptions and reservations
hereinafter provided.
And Grantor warrant and defend the title against the lawful claims of all persons claiming by,
through or under Grantor, and none other, subject to: Ad valorem taxes for the current and
subsequent years not yet due and payable, any recorded easements, restrictions and other
encumbrances of record.
[Signature and Acknowledgement on Following Page]
00274-022/CO236063-I 2 of 3

BK 8375 PG 0173
IN WITNESS ,, EREOF,the Grantor has duly executed the foregoing as of the day and
year first abAa wr• -
a .
Ali Niakorg
Zahra V la'
e di N.Shirazi
Laura Shirazi
State of Nv a'tt(Cray*
County of Li 0110
I certi that-the followin g persons personally appeared before me thisday,each acknowledging to me
that he or she signed the foregoing document: All Niakougialliq IY►a,�Valaie.
Date: l l! '7ti1.— ,,. ,i,, lO S yl.
/ Z Notary-Public—V
Union -n
County n
,Notary Public = My Comm.Exp.
• %
Notary's Print d or Typed e y 06-10-2023
(Official/Notarial Seal) My commission expires: $
•
State of lx
.
County of
I certify that the fo owing person(s)personally appeared before me this day,each acknowledging to me
that he or she signed the foregoing document: Mehdi Shirazi and Laura Shirazi.
Date: OI 2e12 jc n Autdooh
PubilO
� UNcklonb e County,NC
e. w+ ,Notary Public Commission Exp.April30,2024
Notary's P nb or yped Name /r
! (Official/Notarial Seal) My commission expires: t�.jf NCNW/
771 1 I
00274-022/00356063-t 3 of 3

BK 8375 PG 0174
EXHIBIT A
Legal Description
Lying and being situate in Union County,North Carolina,and being more particularly described as
follows:
Lying and being situate in Union County, North Carolina,and being more particularly described
as follows:
BEING all of Lots 13, 14, 15,21 and 22 of SUN VALLEY PARK subdivision as shown on the
map thereof recorded in Plat Cabinet K at 677 in the Union County Public Registry,
1
i
00274.022/00356063-1 4 of 3

DURBAN
GROUP
September 16,2022
Re: 5710 W. Highway 74, Indian Trail,NC(the "Property")
To Whom It May Concern:
The undersigned owns the aforementioned Property located at 5710 W. Highway 74 in
Indian Trail, Union County,North Carolina having tax parcel identification number 07069102.
The undersigned owner of the Property, on behalf of itself,members/managers and affiliated
entities,hereby provides its written consent for Indian Trail PSA, LLC and any of its affiliated
entities (including Durban Development, LLC)and their agents (collectively,"Durban"), to act
on behalf of the undersigned to file or apply for any permits,approvals and/or general
entitlements for development of the aforementioned Property for its intended use, including but
not limited to the following:
• Submitting a financial responsibility/ownership form(FRO) for the Property;
• Authorization for land-disturbing activity on the Property;
• Authorization for Durban to maintain erosion control measures throughout all phases of
construction until the site is closed out;and/or
• Authorization for Durban to provide all adequate measures for any proposed land
disturbance.
To the extent any additional authorization is required in order for Durban to proceed with
obtaining all approvals necessary for development of the Property for the Highway 74
Development(Project ID: UNION-2022-050),the undersigned authorizes same.
Take 5 Carolinas Property Company, LLC
Signed:
Name: l\, A v- /V1,
111
The Durban Group, LLC
Charlotte 106 Foster Avenue, Charlotte, NC 28203 Tel: [phone] / Fax: [phone]
Pittsburgh 5500 Brooktree Road, Suite 303, Wexford, PA 15090 Tel: [phone] / Fax: [phone]
durbangroup . com