NCC223029_FRO Submitted_20220914

DocuSign Envelope ID: 8A62511 B-12AA-43C3-B742-8CDCFF6DC9BD
DocuSign Envelope ID: F6FOA69D-E22E-48OF-BF01-CB4AE1BE2FB6
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. Take 5 Car Wash
1. Project Name
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street North Highway 29 Latitude 35.42823526248138 Longitude-80.61216266905843
3. Approximate date land -disturbing activity will commence: 6/1 /2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
DS
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): x 1.9 [(�-
6. Amount of fee enclosed: $130.00 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mark DeSouza E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Narragansett Realty Co., Inc.
Name
Telephone Fax Number
65 Valley St.
Current Mailing Address
Current Street Address
E Providence, RI 02914
City State Zip
City State Zip
10. Deed Book No. Page No.
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.
Boing US Holdco, Inc.
Scott.O'[e-mail]
Name
E-mail Address
440 Church Street, Suite 700
440 Church Street, Suite 700
Current Mailing Address
Current Street Address
Charlotte, NC 28202
Charlotte, NC 28202
city State Zip
City State Zip
Telephone[phone]
Fax Number

DocuSign Envelope ID: 8A62511 B-12AA-43C3-B742-8CDCFF6DC9BD
DocuSign Envelope ID: F6FOA69D-E22E-480E-BF01-CB4AE1BE2FB6
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:
CT Corporation System
Name
160 Mine Lake Ct., Suite 200
Current Mailing Address
Raleigh, NC 27615
City State
E-mail Address
160 Mine Lake Ct., Suite 200
Current Street Address
Raleigh, NC 27515
Zip City
Telephone 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:
Name of Registered Agent
Current Mailing Address
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 'Omelia
Type or mv��&A
By:
Signature
Executive Vice President
Title or Authority
vl /11, ?off/
Date
I, JOB-�2.V1 Jac. �r� a.,�ov— , a Notary Public of the County of i n
State of� ,hereby certify that Scott O'Melia appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.in his capacity as Executive vice President of Boing US Holdco, Inc.
Witness my hand and notarial seal, this ('q day of 3kW 2U_
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