NCC223414_FRO Submitted_20220930

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. MILLS RIVER STORAGE
1. Project Name
2. Location of land -disturbing activity: County HENDERSON City, or Township MILLS RIVER
Highway/Street NC280-BOYLSTONHWY Latitude34051'1.47" N Longitude77028'29.89" W
3. Approximate date land -disturbing activity will commence: JULY 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): COMMERCIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.6 AC.
6. Amount of fee enclosed: $ 500 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900,00).
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 John E Sikorski E-mail Address
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MILLS RIVER STORAGE, LLC [phone]
Name Telephone Fax Number
108 Angeline Rd. same as mailing
Current Mailing Address Current Street Address
Mills River, NC 28759-4180 same as mailing
City State Zip City State Zip
10. Deed Book No. 3713 page No. 441-443 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.
MILLS RIVER STORAGE, LLC
Name E-mail Address
108 ANGELINE RD. SAME AS MAILING
Current Mailing Address Current Street Address
MILLS FIVER, NC 28759-4180 SAME AS MAILING
City State Zip City State Zip
919-624-0564
Telephone __ _ Fax Number

Z_ (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:
John E Slkorski
Name of Registered Agent
108 ANGELINE RD.
Current Mailing Address
MILLS RIVER NC
City
State
Telephone [phone]
28759
Zip
E-mail Address
(SAME AS MAILING)
Current Street Address
(SAME AS MAILING)
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.
John E Sikorski
Type or print name
General Manager
Title or Authority
Sigr4eure Date
//I
,�y� 1, Lima 11 l' :5yulkLL a Notary Public of the County of
State of North Carolina, hereby certify that t KAYS k appeared U
personally before me this day and being duly sworn acknowledged that the qt;i fprLgb nos
executed by him.
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Witness m hand and notarial sea[, this A 20 ,. 13E G ��.
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Seal
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