NCC223278_FRO Submitted_20221010

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 orprint and, if the question is not applicable or the e-mail address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Iron Mountain Storage
2. Location of land -disturbing activity: County Stokes City or Township King
600 Block Newsome Rd. 36.266 80.385
Highway/Street LatltUd@(decimaldegrees} Longitude{decimal degrees)
911(2022
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Commercial.
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.18
6. Amount of fee enclosed: $300.00 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 Eg No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:.
Name Stephen Eads E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
2010 Enterprise, LLC 336-972-9680
Name Phone: Office # Mobile #
PO Box 2530 710 Kirby Rd.
Current Mailing Address Current Street Address
King NC 27021 King NC 27021
City State Zip City State Zip
10. Deed Book No. 746 Page No. 161, 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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
2010 Enterprise, LLC [e-mail]
Company Name E-mail Address
PO Box 2530 710 Kirby Rd.
Current Mailing Address Current Street Address
King NC 27021 King NC 27021
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) Ifthe 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:
Stephen Eads [e-mail]
Name of Registered Agent E-mail Address
1094 Lilly Drive 1094 Lilly Drive
Current Mailing Address Current Street Address
Tobaccoville NC 27050 Tobaccoville NC 27050
City State Zip City State Zip
Phone: Office # 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 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.
Stephen Eads President
Type or print name Title or Authority
Signature Date
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I, a Notary Public of the County of 346�es
State of North Carolina, hereby certify that ` Q tj f5,ds _ _appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
c
Witness my hand and notarial seal, this ( day of Krk 20
JACKIE C LANKFOR0
NOVARY PUBLIC
STOKES COUNTY ota ry
MY COMMISStPOAXPIRES
My commission expirest�}