NCC223669_FRO Submitted_20221031

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 10 Federal Self Storage Expansion
2. Location of land -disturbing activity: County Nash City or Township Rocky Mount
1117 S Wesleyan Blvd 35.92294-77.83024
Highway/Street Latltude(decimal degrees) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: Summer 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.37
6. Amount of fee enclosed: $ 300 . 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 ❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameCurtis Andrews E-mail Address [e-mail]
Phone: Office # 252-446-2311 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Andrews Investment Management, LLC 252-446-2311 252-813-2910
Name
1117 S Wesleyan Blvd
Phone: Office # Mobile #
Same
Current Mailing Address Current Street Address
Rocky Mount NC 27803
City State
10. Deed Book No. 1 397
Zip City
Page No. 339
State
Zip
Provide a copy of the most current deed.

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).
Andrews Investment Management, LLC
Company Name
1117 S Wesleyan Blvd
Current Mailing Address
Rocky Mount NC 27803
[e-mail]
E-mail Address
Same
Current Street Address
City State Zip City State
Phone: Office # 252-446-2311 Mobile # [phone]
WE
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:
Curtis Andrews
Name of Registered Agent
1117 S Wesleyan Blvd
Current Mailing Address
Rocky Mount NC 27803
City State Zip
Phone: Office # 252-446-2311
[e-mail]
E-mail Address
Same
Current Street Address
City
State Zip
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
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
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.
CUK -r i s A 1J nRE w s
Type or print name
o
Signature
Title or Authorit
Date
?j - g • Zo 2'L—
a Notary Public of the County of
State of North Carolina, hereby certify that �� ,.-�i s �`-1�1�t)S 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
J. KEVIN VAR
NELL
Notary Public
North !Carolina
Edgecombe County
day of /�'t a-��i� 20 `Z'Z--
Not
My commission expires �� �3