NCC233671_FRO Submitted_20231213

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM 9y 7.9 2022
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before
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 Martin Self Storage Leland
2. Location of land-disturbing activity: County Brunswick City or Township Town Creek
7815 Ocean Highway E -S4AC11°146,6. _ a,ez.1-1•40
Highway/Street (Us Hwy 17) Latitude 34°11'53.6"N Longitude_78°3'58.06"W
3. Approximate date land-disturbing activity will commence: TBD
4. Purpose of development(residential, commercial, industrial,institutional,etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 6.0 Ac.
6_ Amount of fee enclosed: $ CO6' ,oo . 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 Charlie Cazier E-mail Address charlieaintracoastalengineering.com
Telephone [phone] Cell# 910-409-3567 W^ Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
7815 Ocean Highway E. , LLC (910) 452-5666
Name Telephone Fax Number
PO BOX 16709 7815 Ocean Highway E.
Current Mailing Address Current Street Address
Wilmington, NC 28408 Leland, NC 28451
City State Zip City State Zip
10. Deed Book No.4572,3970,4697 page No. 769,619,96 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):
7815 Ocean Highway E. , LLC [e-mail]
Name E-mail Address
PO BOX 16709 7815 Ocean Highway E.
Current Mailing Address Current Street Address
Wilmington, NC 28408 Leland, NC 28451
City State Zip City State Zip
Telephone (910) 452-5666 Fax Number

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:
James Martin Mrtnjmsl'aol.com
Name of Registered Agent E-mail Address
PO BOX 16709 7815 Ocean Highway E.
Current Mailing Address Current Street Address
Wilmington, NC 28408 Leland, NC 28451
City State Zip City State Zip
Telephone (910) 452-5666 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.
James Martin Manager _
Ty or print name Title or Authority
c_i- /- 7 -2r2
' ature Date
1, vk4-qN% \LQ , , a Notary Public of the County of te.� �� 1LQ-
State of North Carolina, hereby certify that --Itm..1/44.,> V\.,. \`&KAtJ 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 �'� day of ��Vt�, , 20 '2.,')_
Brittany Venth
Noy PUBLIC
New Hanover County My commission expires karir Z-1 �..% )-�
North Carolina u
My Commission Expires August 8,2028