NCC230004_FRO Submitted_20230104

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1
2.
3.
4.
Project Name New Self Storage Facility
Location of land -disturbing activity: County WIIkeS City or Township North Wilkesboro
Hwy 268 East (Elkin Hwy) 36.18 -81.12
Highway/Street LatltUde(decimal degrees) LOngltUde(decimal degrees)
Approximate date land -disturbing activity will commence. December 12, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 5.22
6. Amount of fee enclosed: $ 600.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Martin Cheek E-mail Address [e-mail]
Phone: Office # 336-927-0642 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Cheek's Water Works, INC. 336-927-0642
Name Phone: Office #
PO Box 199 309 Ninth Street
Current Mailing Address Current Street Address
Wilkesboro NC 28697 North Wilkeboro NC
City
10. Deed Book No. 1 362
State
Zip City
Page No 186
State
Mobile #
28659
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s). the name(s) of the owner(s) may be listed as the financially responsible party(ies)
Cheek's Water Works, INC.
Company Name
309 Ninth Street
Current Mailing Address
North Wilkesboro NC 28659
City State Zip
Phone: office # 336-927-0642
[e-mail]
E-mail Address
309 Ninth Street
Current Street Address
North Wilkesboro NC 28659
City State Zip
Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
G. Martin Cheek
Name of Registered Agent
309 Ninth Street
Current Mailing Address
North Wilkesboro NC 28659
City
State
[e-mail]
E-mail Address
309 Ninth Street
Current Street Address
North Wilkesboro NC 28659
Zip City
Phone: office # 336-927-0642 Mobile #
Martin Cheek
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the INC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
M hp- ,J FCC
Type or print na
i -
Signature
Title or Authority
Date
I,fi&'�M, a Notary Public of the County of O/—A-S-
State of North Carolina, hereby certify that G. MO in C� ee_ Tr, appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her-
Witness my hand and notarial seal, this 4!� day of Af teri-A cr— 20Z2
Notary
Seal
My commission expiresT 2r2Y
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