NCC216003_FRO Submitted_20211028

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 Environment and Natural Resources. (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.
1. Project Name Sadat Automotive
2. Location of land -disturbing activity: County Franklin City or Township Youngsville
Sunset Dr 36.02304-78.51246
Highway/Street Latitude Longitude
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.10 AC
6. Amount of fee enclosed: $ 195 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dwight Elam E-mail Address [e-mail]
Telephone [phone] Cell # n/a Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Nazir Ahmad Shah Ghulam Hassan
n/a n/a
Name
Telephone Fax Number
717 Tree Green Ln
n/a
Current Mailing Address
Current Street Address
Wake Forest NC 27287
n/a n/a n/a
City State Zip
City State Zip
10. Deed Book No. 2264 Page No.
1924 - 1925 Provide a copy of the most current deed.
Part B.
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):
Nazir Ahmad Shah Ghulam Hassan
[e-mail]
Name
E-mail Address
717 Tree Green Ln
Same
Current Mailing Address
Current Street Address
Wake Forest NC 27587
City State Zip
City State Zip
518.867.6946
n/a
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.
Nazir Ahmad Shah Ghulam Hassan Owner
Type or print name
Title or Authority
Signature Date
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, a Notary Public of the County of
State of North Carolina, hereby certify that 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 day of 20
Notary
Seal
My commission expires