NCC232028_FRO Submitted_20230711

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 S. Memorial Drive Latitude(decimal degrees)35.5600 Longitude(decimal degrees)-77.4060
3. Approximate date land-disturbing activity will commence:June, 1, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.2 AC
6. Amount of fee enclosed: $220.00 . 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 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 - Memorial 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.4365 Page No.481 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).
Greenville - Memorial 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 - Memorial 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.
Greenville - Memorial Take Five, LLC Manager
Type or print name Title or Authority
03Ai143
Signature Date
I, %• 3 lanol Tokt , a Notary Public of the County of MW til eGk-1'.4uf/.+
State of North Carolina, hereby certify that Glen Cherry 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 49 day of kkawC I t , 20 2.3
D. Ryland PondV.C;:7
NOTARY PUBLIC Notary
Seecklenburg County
North Carolina Mycommission expires £0 'I�l'20Z(
My C'�rnmission Expires October 14,2025 p

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 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#

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Type: CONSOLIDATED REAl;1,..E.,EiOF.7.001TY . ..
, Recorded: 12/19/2022 3:26:1,2,,P.O.,: ::.'''....' *
Fee Amt: $3,126.00 Page 1.of"4:','••;:..;.. .:',?` .
• Revenue Tax: $3,100.00 ,'.. '.j'.'V;.:;.,-...:. • . .
Pitt County, NC , i,',*::%1.' .'?•,...,, ••••
Lisa P. Nichols REG OF DEE154',::,:,•: ;•:,'
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BK 4365 PG 481.,..484'
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' NORTH CAROLINA SPECIAL WARRANTY DEED • ._
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• PITT'COUNTY
This instrument prepared by: EXCISE TAX:$3,100.00
Christian E.Porter,Attorney Parcel Identifier No: 72902
1698 E.Arlington Blvd.,Greenville,NC 27858 ' •
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*No title examination performed by this preparing attorney. ••:,'.'' :';!.:',,--cp:•::,.....', . The property herein conveyed does not include
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the primary residence of the Grantor,
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Mail/Return to: Grantee,
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THIS DEED made and entered into this /4--L day of 2022, by and between •
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GRANTOR .,,.t. -; .••.;;;.: •
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, . MEMWIN 3810 LLC " ''GWONILLE-.MEMORIAL TAKE FIVE,LLC •
a Georgia limited liability company • •-..' ;*IN'Orth Carolina limited liability company,
2055 Brockton Close •. :.,"1.4,...,,... 4,,.,:i:. 106 Foster Avenue
Marietta, GA 30068 Charlotte,NC 28203 •
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The designation Grantor and Grantee as used herein shall inclifd6.:saicI their heirs, successors, and assigns, and shall include
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singular,plural,masculine,feminine,or neuter,as required by context
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That, Grantor for Ten Dollars ($10.00) and.other good and valuable consideration, has bargained and .
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sold and by these presents does hereby bargain, sell, arid convey unto Grantee that certain lot or parcel of land
more particularly described as follows: .
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Submitted electronically by "Chicago Title Company, LLC"
00367060-1 in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Pitt County Register of Deeds.
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Book:4365 Page:481 Page 1 of 4 . 4

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Deed ,-,,` '.';:•;' r';
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BEING all of Pitt County Tax Parcel;4p729,02.•and being more particularly• . .
.. described as follows:
Pink• . c„ i',:: '
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BEING all of Lot 1 of Orange Acres'.'Subdivision, as same is shown on plat 4.;
thereof recorded in Nat Book 56, at•Page;176 n the Office of the Register of . {_
Deeds for Pitt County,North Carolina.-;.,;;..r';y,,::; ;
TO HAVE AND TO HOLD the foregoing',desc.+i`ribed,:lot or parcel of land and all privileges and
appurtenances thereunto belonging or in anywise appertairu g. nto the said Grantee in fee simple forever.
And the said Grantor does hereby covenant that;.it;:�has done nothing to impair such title as it received and
that it will warrant and defend the title to the same against:tl e'lawful claims of all persons claiming by, through, •
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under or on account of it, other than the following exceptions:;;r',: ,
• ' 1. Taxes for the year 2023 and subsequent years;.a l'iennot yet due and payable; .
2. Easements and general utility easements affecting;�tl e'property of record in the Pitt County Registry;• • -
3. Any and all federal, state or local regulation',1,::..,,;.;elated to zoning, land use or development of the - '
property; and :••1,•; ; ;:;,
4. Highway or road rights of wayaffectingthe`Ypkbpeity of record in,the Pitt CountyRegistry. .
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IN TESTIMONY WHEREOF, the said Grantoi has `ereunto duly executed this instrument this the day
• and year first above written. `'.., ''•,
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[signature follows';o ; ext page] • .
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00367060-1 .,.Y'.. q;,;,i:`
Book:4365 Page:481 Page 2 of 4 • •

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Deed ':;; ;:.:' ,",' •
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MEMWIN,3•81�i.ELC
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'BY: , ,
• •QINGQUANNIE, Manager ••
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STATE OF rem-_,J V c� • '''
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COUNTY OF
I certify that the following person(s) personally,a? feared: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: QINGQUAN NIE,Manager of MEMWIN;3;8'10' LAC
Witness my hand and Notary Seal this the ''/.'.,f'' t<<r'�`.,.`day of December, 2022. •
[AFFIX NOTARY SEAL BELOW] " 1'`r'a .t'r .
.. STATE s.co . ,:•w, '
P. OF NEW YORK 'FT.1,`y;, ',1'.;,'; ', ,
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My Commission Expires: � 2.2: 2�Z., 14•..' .
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Book:4365 Page:481 Page 3 of 4 '

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• Consent of Sole Member
MEMW IN 3 t310,LLC •
Sale to Leo Long Nguyen
Page 2 of 2
EXHIBIT "A"
BEING all of Pitt County Tax Parcel # 72902 and being more particularly
described as follows:
BEING all of Lot 1 of Orange Acres Subdivision, as same is shown on plat
thereof recorded in Plat Book 56, at Page 176 in the Office of the Register of
Deeds for Pitt County,North Carolina.
003670674
Book:4365 Page:481 Page 4 of 4