Loading...
HomeMy WebLinkAboutNCC216552_FRO Submitted_20211130FINANCIAL 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 and/ or fax information unavailable, place N/A in the blank.) Part A. All Seasons Self Storage Phase V at Walker Street 1. Project Name g 2. Location of land -disturbing activity: County ChoWan City or Township Edenton Highway/Street North Oakum St. Latitude 36.0711400 N Longitude-76.5997600 W 3. Approximate date land -disturbing activity will commence: October 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.9 6, Amount of fee enclosed: $ 390.00 . 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 X No Enclosed X Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Tom Gandee E-mail Address tgandee@gmail.com Telephone Cell # 252.333.8014 Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners) Coogan Assets, LLC 252.333.8014 Name Telephone Fax Number PO Box 197 117 Blount Street Current Mailing Address Current Street Address Edenton NC 27932 Edenton NC 27932 City State Zip City State Zip 10. Deed Book No. 544 Page No.173 Provide a copy of the most current deed. Part B. 1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship, the name of the owner or manager may be listed as the financially responsible party. Coogan Assets, LLC tgandee@gmail.com Name E-mail Address PO Box 197 117 Blount Street Current Mailing Address Current Street Address Edenton NC 27932 Edenton NC 27932 City State Zip City State Zip Telephone 252.333.8014 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 Current Mailing Address City Telephone. E-mail Address Current Street Address State Zip City State Zip 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 Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City State Zip 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. Thomas Gandee Type or pr. t ame Signature Manager Title or Authority '4�. /9 Date I, _ �'W�S a Notary Public of the County of UOn State of North Carolina, hereby certify that IA'e C, 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 2011 �.+:�NEY yO Odrolo Seal S Cal-1N�. WAW�AA VkAUN Notary My commission expires nWns