NCC232995_FRO Submitted_20231010

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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Cardinal Self Storage
2. Location of land-disturbing activity: County Moore City or Township Aberdeen
Highway/Street US 15/501 Latitude 35-09'15"N Longitude 79-25'04"W
3. Approximate date land-disturbing activity will commence: June 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.946 AC
6. Amount of fee enclosed: $130.00 The application fee of$65.00 per acre (rounded up to the next acre)
is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
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 Lee Humphrey E-mail Address Leendoubledena.com
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cardinal Self Storage Aberdeen, LLC [phone]
Name Telephone Fax Number
3200 Rugby Road Same
Current Mailing Address Current Street Address
Durham NC 27707 Same
City State Zip City State Zip
10. Deed Book No. 5227 Page No. 478 Provide a copy of the most current deed.
Deed Book No. 5270 Page No. 475
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):
Cardinal Self Storage Aberdeen. LLC ChriosaAol.com
Name E-mail Address
3200 Rugby Road Same
Current Mailing Address Current Street Address
Durham NC 27707 Same
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 be any change in the information provided herein.
Chris Sanders Managing Partner
Ty e or print nam LiAro
Title or Authority
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nature
Date
1
I, L&e( �' /161- , a Notary Public of the County of 4V,�tia
State of North Carolina, hereby certify that Ch tom, c SMOI s appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this I ` day of /j , 20 2
Notary'
n
TO MP PHELPS , 0?���
Notary PI;hlic My commission expires
Wake.Go. Nor'c arclina
My Commission Expires Apr.20.2022