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