NCC231796_FRO Submitted_20230609

FINANCIAL RESPONSIBILITY/OWNER HIP FORM
SEDIMENTATION POLLUTION CON ROL ACT
No person may initiate any land-disturbing activity on one or more a res 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 R-sources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unay.,ilable, place N/A in the blank.)
Part A.
1. Project Name Lakeside Self-Stora•e
2. Location of land-disturbing activity: County Harnett City or Township Black River
Highway/Street NC-2/0 Latitude 35.469755° N Longitude 78.779747° W
3. Approximate date land-disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, instiLitional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.5 AC
6. Amount of fee enclosed: $ 585.00 . The appli tion fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Exam le: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues ari during land-disturbing activity:
Name John L. Auton E-mail Address [e-mail]
Telephone [phone] Cell # 919-369-9872 Fax #
9. Landowner(s) of Record (attach accompanied page to list addition I owners):
Larue M. Powell 919-427-3960
Name Telephone Fax Number
7036 Rouse Road 7036 Rouse Road
Current Mailing Address Current Street Address
Holly Springs NC 27540 Holly Springs NC 27540
City State Zip City State Zip
10. Deed Book No. 3826 Page No. 0591 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):
Imperial Self Storage Development, Inc. jauton@1SSDlnc,com
Name E-mail Address
6917 NC-55 6917 NC-55
Current Mailing Address Current Street Ad ress
Fuquay-Varina NC 27526 -V r. 2
City State Zip City State Zip
Telephone [phone] 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.
John L.Auton-imperial Self Storage President
Type print name Title or Authority
7 (7"— Dgl) 3) �,
Signat re Date
I, OrrieLl ZP:--1-, ad n`_T a Notary Public of he County of r\av n-a--I--
State of North Carolina, hereby certify that 571 0 LOC9t,/inNA ,a appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
7AiC..
Witness my hand and notarial seal, this (, dday of Lrt � i
, 20 &
aa
CASEY RUSS EVANS c I v 0
Notary Public, North Carolina çOI
a
Harnett County ry (y� ) ,
S''y -m is Dn7�1 Aires My commission expires I I l(, �1 2`t