NCC221855_FRO Submitted_20220519

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 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.)
1. Project Name Hickory Run at River Trace
2. Location of land -disturbing activity: County, Craven City or Township- Township No. 7
Highway/Street NCSR 1144 Latitude 35.0619480 — Longitude -77.0920260
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 36.9Acres
6. Amount of fee enclosed:$ 3,700.00 . The application fee of $100.00 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Avolis, PE E-mail Address kevin(cD-avoliseng.com
Telephone [phone] Cell # 252.671.9333 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Brices Creek Mini Storage, LLC 252.636.5556
Name Telephone Fax Number
PO Box 15564 1855 Brices Creek Road
Current Mailing Address Current Street Address
New Bern, NC 28561 New Bern, NC 28562
City State Zip city State Zip
10. Deed Book No. 3686 Page No. 1242 - 1244 Provide a copy of the most current deed.
Part B.
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.
Brices Creek Mini Stora-ge, LLC
Name E-mail Address
PO Box 15564 1855 Brices Creek Road
Current Mailing Address Current Street Address
New Bern, NC 28561 New Bern, NC 28562
City State Zip city State Zip
Telephone [phone] 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:
Name of Registered Agent
Current Mailing Address
City
Telephone
rat", ".K.T.T.T-M
Current Street Address
State Zip city State Zip
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.
Dwight Merchant Member/Manager
Type or print name Title or Authority
November 15, 2021
Signature Date
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1, Beth Simmons , a Notary Public of the County of Craven
State of North Carolina, hereby certify that Dwight Merchant 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 1 5th day of November 20 21
BETH SIMMONS Notary
Se *-TARy pUIBUC
CRAVEN COUNTY, NC My commission expires April 22, 2024
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