NCC216879_FRO Submitted_20211217

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 NIA in the blank.)
Part A.
1. Project Name I STORAGE STATION, LLC. SELF STORAGE-]
2. Location of land -disturbing activity: County MARTIN City or Township WILLIAMSTON
Highway/Street S. US 17 BUS Latitude 35.836330 Longitude-77,064902
3. Approximate date land -disturbing activity will commence: DEC. 6, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): COMMERCIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.54
6. Amount of fee enclosed: $ 195.00 . 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 WAYLAND SPRUILL E-mail Address [e-mail]
Telephone [phone] Cell # NIA Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MARY PEELS LILLEY N/A
Name Telephone Fax Number
300 CEDAR LANE 300 CEDAR LANE
Current Mailing Address Current Street Address
WILLIAMSTON NC 27892 WILLIAMSTON, NC 27892
City State Zip City State Zip
A PORTION OF
10. Deed Book No. 0R-27 Page No. 656 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):
STORAGE STATION, LLC wayland.spruill(ED-icloud.com
Name E-mail Address
310 US HWY 13/17 SOUTH 310 US HWY 13/17 SOUTH
Current Mailing Address Current Street Address
WINDSOR NC 27983 WINDSOR, NC 27983
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.
WAYLAND O. SPRUILL REGISTERED AGENT
Type or print name Title or Authority
o. /o z0;) r
Signatuf6 V Date
i, '7e;y- M ^az.l , a Notary Public of the County of�&___,_/f e
State of North Carolina, hereby certify that WCV4 10 0['u_i I appeared
personally before me this day and being duly worn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this ��day of 20 �
BETTY DOZIER Am,,
Notary Public Notary
Seal Bertie County, NC
My Commission Expires August 30, 2023 My commission expires ��