NCC221908_FRO Submitted_20220519

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name AVAILABLE STORAGE CO.
2. Location of land -disturbing activity: County Yadkin City or Township Yadkinville
Highway/Street Hoots Road_Latltude(decimaldegrees) 36'1174 Long itude(decimal degrees) -80.7030
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.07
6. Amount of fee enclosed: $ 400.00 . 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed EX No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robert Baldwin E-mail Address [e-mail]
Phone: Office #
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mill Avenue RE, LLC
Name
802 Northern Shores Lane
Current Mailing Address
Greensboro, INC 27455
City
[phone]
Phone: Office #
Current Street Address
State Zip City
State
Mobile #
Zip
10. Deed Book No. 1345 Page No. 0037 Provide a copy of the most current deed.
(Plat Book 13, Page 139)

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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Max Land Holding, LLC [e-mail]
Company Name E-mail Address
323 Riverbend Drive
Current Mailing Address Current Street Address
Advance, NC 27006
City State Zip City State Zip
Phone: Office # 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:
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)
(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.
Robert BaldvfiW
Type or pri n
Signatu e
Manager
Title or Authority
3 /z3 IZ2-
Date
I, erNpnl a Notary Public of the County of bVcdSoo
State of North Carolina, hereby certify that tn 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 O�day of May-Lh 20�_
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NOTAAy
My commission expires abD_a-
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