NCC230615_FRO Submitted_20230308

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
Project Name: HOME21 TRU HOTEL
2. Location of land -disturbing activity: County CABARRUS City or Township CONCORD
Highway/Street 5365 JOHN Q HAMMONS DR NW Latitude35.363008 Longitude-80.700866
3. Approximate date land -disturbing activity will commence: FEBRUARY 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): COMMERCIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.5 AC
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.
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 ASHOK PATEL E-mail Address ashok namanhotels.com
Phone: Office # 843.669.0855 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NAMAN SPEEDWAY I LLC 843.669.0855 917-379-6770
Name Phone: Office # Mobile #
PO BOX 4540 2200-A David McLeod Blvd
Current Mailing Address Current Street Address
Florence SC 29502 Florence SC 29501
City State Zip City State Zip
10. Deed Book.No. 7678 Page No. 151 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 ord the
landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
NAMAN SPEEDWAY I, LL_ C
Company Name
PO BOX 4540
Current Mailing Address
[e-mail]
E-mail Address
2200-A David McLeod Blvd
Current Street Address
Florence SC 29502 Florence SC 29501
City State Zip City State Zip
Phone: Office # 843.669.0855 Mobile # [phone]
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:
NIKHIL PATEL
Name of Registered Agent
PO BOX 4540
Current Mailing Address
Florence SC 29502
City State Zip
[e-mail].
E-mail Address
2200-A David McLeod Blvd
Current Street Address
Florence SC 29501
City State Zip
Phone: Office # 843.669.0855 Mobile # [phone]
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
Current Mailing.Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
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.
_ASHOK PATEL MANAGER
Type or print name Title or Authority
4��. - It t'�' 22
Signature Date I If
� t rI
a Notary Public of the County of I� 4_dl2fitL.�
SOUTH ``-- II
State of NQFt -i-Carolina, hereby certify that �YI� k 1 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 W1)VAW4k_ 20 0 l
Sea',
PRISCILLA S WILLIAMS
NOTARY PUBLIC
SOUTH CAROLINA
MY COMMISSION EXPIRES 06-21-26
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My commission expires