NCC232285_FRO Submitted_20230731

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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. Project Name Kinston Self Storage
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Lenoir City or Township Kinston
Airport Rd SR 1578 35.296861 -77.589047
Highway/Street LatltUde(decimal deges)SeptOngltUde(decimal degrees)
3. Approximate date land-disturbing activity will commence:Spt 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10.42
6. Amount of fee enclosed: $ 1 , 1 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 ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ely Perry [e-mail]
Phone: Office# 252-523-5107 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kinston QOZB, LLC 252-523-5107 252-559-2629
Name Phone: Office# Mobile#
518 Plaza Blvd. 518 Plaza Blvd.
Current Mailing Address Current Street Address
Kinston, NC 28503 Kinston, NC 28503
City o State Zip City State Zip
10. Deed Book No. 1987 Page No.535-542 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).
Kinston QOZB, LLC [e-mail]
Company Name E-mail Address
518 Plaza Blvd. 518 Plaza Blvd.
Current Mailing Address Current Street Address
Kinston NC 28503 Kinston NC 28503
City State Zip City State Zip
Phone: Office# 252-523-5107 Mobile# [phone]
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:
Ely J. Perry Ill [e-mail]
Name of Registered Agent E-mail Address
518 Plaza Blvd. 518 Plaza Blvd.
Current Mailing Address Current Street Address
Kinston NC 28503 Kinston NC 28503
City State Zip City State Zip
Phone: Office# 252-523-5107 Mobile# [phone]
Not Applicable
Name of Individual to Contact(if Registered Agent is a company)
(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 NC Secretary of State business registry:
Not Applicable Not Applicable
Name of Registered Agent E-mail Address
Not Applicable Not Applicable
Current Mailing Address Current Street Address
Not Applicable Not Applicable
City State Zip City State Zip
Phone: Office# Not Applicable Mobile# Not Applicable
Not Applicable
Name of Individual to Contact(if Registered Agent is a company)

(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.
Ely J . Perry III Registered Agent
Type or print name Title or Authority
— /1 , z3
Signatur Date
I, Arnoi D • igh-4- , a Notary Public of the County of L e no i ►r
State of North Carolina, hereby certify that t. ly j• Pe rr/, Z iT 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 '-1 day of j Uf e_ , 20 p,•3
AMANDA D SPEIGHT Ocrrocitict 0• nk
Notary Public.North Carolina Notary
Lonoir County
My Commission Expires
February 09,2027
My commission expires a oci/aoa7

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Not Applicable
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Not Applicable
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Not Applicable
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Not Applicable
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Not Applicable
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Not Applicable _
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Not Applicable
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#