NCC231057_FRO Submitted_20230419

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/2 acre or more inside a
watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning & Development, Erosion Control Section.
(Please type or print)
Part A.
1. Project Name Storage Sense Expansion
2. Location of land -disturbing activity: County Iredell
City or Township Statesville
Highway/Street N. Barkley Road Latitude 35.1Oz13 Longitude_
SR 2532
3. Approximate date land -disturbing activity will commence: February 28, 2022
-80.85822
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5.
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.4 }/- acres
6. Amount of fee enclosed: $ 525.00 . An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a flat fee of $100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Steve Gray E-mail Address [e-mail]
F
10
Telephone [phone] Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
FultonBSH SYNC II, LLC 484-434-8648
Name Telephone Fax Number
1 Presidential Blvd., Suite 201 1 Presidential Blvd., Suite 201
Current Mailing Address Current Street Address
Bala Cynwyd PA 19004 Bala Cynwyd PA 19004
City State Zip City State zip
Deed Book No. 2884 Page No. 1995 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): c/o City Line Capital; Attn: Dominic D'Agostino, Senior Asset Manager
FultonBSH SVNC II, LLC [e-mail]
Name E-mail Address
1 Presidential Blvd., Suite 201 1 Presidential Blvd., Suite 201
Current Mailing Address Current Street Address
Bala Cynwyd PA 19004 Bala Cynwyd PA 19004
City State Zip City State Zip
Telephone [phone] Fax Number
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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:
CT Corporation System
Name E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] 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 by any change in the information provided herein.
Richard Schontz Manager
Type or tint name Title or Authority
i'
02-A/ -2023
Signatur Date
I, KELSEY LEIGH PAGOTTO , a notary Public of the County of MONTGOMERY COMMONWEALTH OF PENNSYLVANIA
hereby certify that Richard Schontz appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him, in his authorized capacity as Manager of Fulton8SH SVNC 11, LLC.
Witness my hand and notarial seal, this day of Fi=BRUARY 2 23
Not ry KELSEY LEIGH PAGOTTO
Seal
7C()M,Mjonw_e8fth o PPennsylvania • Notary Seel
LNliontgomeryJCounl Aar°'%0'1:mmission Expires August 23. 2026ommission Number 133648 7
My commission expires 08-23-2026
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