NCC241785_FRO Submitted_20240618

Env ri oDepartment of
ReceivedQuality
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM DEC 4 2023
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the ANtl f®rsS l@m
form and an acceptable erosion and sedimentation control plan have been completed and a �g � e
Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to Se
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. :)4PCLI 7 C - 034 p
1. Project Name Welcome Self Storage
2. Location of land-disturbing activity: County Davidson City or Township Lexington
Highway/Street Old US Hwy 52 Latitude 35.867881 Longitude -80.249113
3. Approximate date land-disturbing activity will commence: January 02, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.5 ac
6. Amount of fee enclosed: $ 300.00 . 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 © No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Matt Kostelic E-mail Address kortelicgmail.com
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Welcome Self Storage 3, LLC [phone]
Name Phone: Office# Mobile#
3331 Healy Drive 4246V.
Current Mailing Address Current Street Address
Winston-Salem NC 27114
City State Zip City State Zip
10. Deed Book No. 2622 Page No. 114 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).
Welcome Self Storage 3, LLC kortelic(cr�gmail.com
Company Name E-mail Address
3331 Healy Drive 4tzu,gc
Current Mailing Address Current Street Address
Winston-Salem NC 27114
City State Zip City State Zip
Phone: Office# f336) 577-1583 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:
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:
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)
(c) tf 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
Matt Kostelic _._ Owner - President
Type
or print name Title or Authority
o�
�/./ F a • 12/12/2023
Signature Date
1 Jerry W Johnson , a Notary Public of the County of Tarrant
State of North Carolina, hereby certify that tAa i hevv a a GC appeared personally before
me this day and being duly sworn acknowledged that the above form was executed by him/her.
12th December 2023
Witness my hand and notarial seal, this day of , 20 -
o �418/4iiii,
\ ,ip ' 4e`''/— Jerry W Johnson
i • 0;% Notary Jerry W Johnson Notary Public, State of Texas
ID NUMBER
568607-3 07/28/2026
9 Fpp t.*{ COMMISSION EXPIRES My coin imssion expires .....
�77$IIIliil8\l0' July 28.2026
Notarized online using audio-video communication