NCC230432_FRO Submitted_20230215

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 NIA in the blank.)
Part A.
Project NameNORTH STAR STORAGE
'If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
NIA
2. Location of land -disturbing activity: CountyROWAN City or Township
4485 CAUBLE RD. 35.7308-80.4990
Highway/Street
Latitude(decimataegrees) Longitude�deflmard�,ees)
3. Approximate date land -disturbing activity will commence:Aprl 110, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 -6
6. Amount of fee enclosed: $200.00 . 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 fled? Yes ❑ Enclosed ❑ No m
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameThaddeus J. Ogg E-mail [e-mail]
Phone. Office # N/A
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
North Star Storage, LLC NIA
Name Phone: Office #
100 Broad Street PO Box 341 4485 Cauble Rd.
Current Mailing Address
Rockwell NC 28138
704-239-3854
Mobile #
Current Street Address
Salisbury NC 28147
City State Zip City
10. Deed Book No. 1408 Page No.606
State
Zip
Provide a copy of the most current deed.
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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 solo 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).
Thaddeus J. Ogg
[e-mail]
Company Name E-mail Address
340 Shore Acres Rd. 340 Shore Acres Rd.
Current Mailing Address Current Street Address
Salisbury NC 28146 Salisbury NC 28146
City State Zip City State Zip
Phone: office # N/A 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
Thaddeus J. Ogg
Name of Registered Agent
340 Shore Acres Rd.
Current Mailing Address
Salisbury NC 28146
City
State Zip
[e-mail]
E-mail Address
340 Shore Acres Rd.
Current Street Address
Salisbury NC 28146
City State Zip
Phone: office # NIA Mobile # [phone]
NIA
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:
NIA
NIA
Name of Registered Agent E-mail Address
NIA NIA
Current Mailing Address Current Street Address
NIA NIA
City State Zip City
Phone: office # NIA Mobile # NIA
NIA
Name of Individual to Contact (if Registered Agent is a company)
State Zip
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(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.
Thaddeus J. Ogg C.E.O.
Type or print name Title or Authority
Signature Date
I. ) k- , t 'C , a Notary Public of the County of '�\6W C,Y)
State of North Carolina, hereby certify that 'd0.A 6f.k"'-S J �D C S _appeared personally
before me this day and being duly sworn acknowledged that the aboveforrh was executed by him/her.
Witness my hand and notarial seal, this ��day o , 20_a�
011111111111 1 'PI"A-AQ
NoDry
?O�ARr My commission expires
•' O �.
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