NCC231924_FRO Submitted_20230628

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville(Title 9,Chapter 8)before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Greenville,
Engineering Department. (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 Take Five Oil Change
2. Location of land-disturbing activity: County Pitt City or Township Greenville
Highway/Street East Fire Tower Road Latitude(decimai degrees)35.5658 Longitude(decimai degrees)-77.3589
3. Approximate date land-disturbing activity will commence: May, 29, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.90 AC
6. Amount of fee enclosed: $100.00 . The application fee of$100.00 per acre or portion
thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre
application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 2 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jake Potter E-mail [e-mail]
Phone: Office# 704-319-8344 Mobile# N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Greenville - Fire Tower Take Five, LLC 704-319-8330 N/A
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. �101 Page No. 6`I 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)maybe listed as the financially responsible party(ies).
Greenville - Fire Tower Take Five, 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# 704-319-8330 Mobile# N/A
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:
Greenville - Fire Tower Take Five, 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# 704-319-8330 Mobile# N/A
Glen Cherry
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 D. Chcrry C. Co11;g4I c45 Manager
Type or print name Title or Authority
Oature
0gUo/10 Date
I, D. Ryland Pond , a Notary Public of the County of Mecklenburg
•State of North Carolina, hereby certify that Clcn D. Chi C. COIlf., 4! 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 GA.(' day of likal , 20 Z3
D. Ryland Pond
NOTARY PUBLIC Notary
Saecklenburg County
North Carolina My commission expires /o-p`t-ace f
My Commission Expires October 14,2025

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:
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 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 I 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#