NCC232293_FRO Submitted_20230807

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 NCGO1 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 USA Storage - Kannapolis
'If This projecl 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. Locaticn of land-disturbing activity: County Cabarrus City or Township Kannapolis
5719 Wabash Lane 35.421170 -80 673350
Highway/Street Latitude:dearrai degrees) Longitude;ceanrai degrees)
3. Approximate date land-disturbing activity will commence:August 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):2.30
6. 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-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 Philip Cranmer E-mail Address [e-mail]
Phone: Office# 404-964-9122 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
STOR CONNC KANNAPOLIS, LLC
Name Phone: Office# Mobile#
160 Mine Lake Ct. Ste. 200
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
10. Deed Book No. 00019 Page No.00001 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 individua!(s), the name(s)of the owner(s)may be fisted as the financially responsible party(ies)
STOR CONNC KANNAPOLIS, LLC [e-mail]
Company Name E-mail Address
2821 2nd Avenue, Suite M 2821 2nd Avenue, Suite M
Current Mailing Address Current Street Address
Birmingham, AL 35233 Birmingham, AL 35233
City State Zip City State Zip
Phone: Office# 404-643-8245 Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Suite 200 160 Mine Lake Ct Suite 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# 919-944-4780 Mobile#
Erin Sanders
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.
l Gars t . /c1' President of STOR CONNC KANNAPOLIS, LLC
Type or rint r Title or Authority
V8/.2
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Signs / Date
I, -oSer4 Geri , a Notary Public of the County of J�ka lb
Gcorr State of-Ne efi , hereby certify that ."Ks A.&crd-- 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 D fit day ofebraa , 20
flo PH � �'k. t/t4)
Notary 9,94
M:a �•i = My commission expires � a��q'�� 1 f