NCC230777_FRO Submitted_20230322

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.)
Part A. Surf City E-Z Mini Storage
1. Project fume
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3.
4.
5.
6.
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Location of land -disturbing activity: County Pender
NC H' h 50
City or Township Surf City
Highway/Street Ig Way Latitude Longitude
Approximate date land -disturbing activity will commence: February 2023
Purpose of development (residential, commercial, industrial, institutional, etc. ): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.99
Amount of fee enclosed: $ 300 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).
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 Kurt Taylor
E-mail Address [e-mail]
Telephone [phone] Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Topsail Self Storage, LLC
[phone]
Name
Telephone Fax Number
1809 Hawthorne Rd
14001 NC Highway 50
Current Mailing Address
Current Street Address
Wilmington NC 28403
Surf City NC 28445
City State Zip
City State Zip
10. Deed Book No.4801 Page No.1507 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Topsail Self Storage, LLC
[e-mail]
Name
E-mail Address
1809 Hawthorne Road
Current Mailing Address
Current Street Address
Wilmington NC 28403
City State
Telephone [phone]
Zip City
Fax Number
State
Zip

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
Telephone
State
WE
City
Fax Number
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.
Kurt Taylor
Type or print name
Managing Member
Title or Authority
11 /21 /2022
Signature Date
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a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn ac owledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of 20 �-
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