NCC243091_FRO Submitted_20241016

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one ovmore acres ma covered by the Act, including any
8Ct|V|ty under COrMrOUn plan 8f development ofthis 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
'-~ the appropriate
Regional Office. (Please h/p8 or print and, if the question is not applicable or the e-maile-mail --
dnoaa or phone
number iuunavailable, place N/A in the blank.)
Part A.
1. Project Name: Mountain Shore Mini-Storage
*If this project involves American Rescue Plan Act(ARPA)funds,list the Name be�wund���
you a��df��m�g�m�h�eD��nofNa� r� rahno�� (DWN '
hw Project
AR.PA'Funded�������``/�����``��AROu Project
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No
2. Location Of land-disturbing activity: County: St8Dk/ City Ur Township: New London
Highvvav/Stn*et: NC Hwy 62 Lat|tude: 35.4367UO LonQitude:-80.217OOO
3. Approximate date land-disturbing activity will commence: 5/20/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.90
S. The application fee of $1QU.UO per acre (rounded up to the next acre) is assessed without a ceilingamount (Exmnnp|e: O.1O-aone application fee ka $0O8). '
7. Has an erosion and sediment control plan been filed? Yae-VViUbeyNai|edorHand-De|ivered
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Charles McConkey E-mail Address: [e-mail]
Phone: 338-8BO-8704 K0ubi|n:
9. Lgnd[xwner(S) 0fRecord:
`^°����' '� � La d ^ `
Namo�`��^��w��»^ �.�'~ � ' /� � ������ E%ma0-��'�.�����`.�'�,`���� '. - Mobile Phone,
Mountain Shore Properties, LUC Chuck
.� - '
' Mailing AddressStreet 1 `
. ' city . ' city - ' ^
841 �� �. NC`' ' ^ - /= 594 ' ^^ -nton StateNC 27239
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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(iss).
Prima Financially Responsible Party
Company Name Email Business Phone Mobile Phone
Mountain Shore Properties, LLC [e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street l City State Zip
941 Randolph Thomasville NC 27360 P.O. Box 594 Denton NC 27239
Street
Additional Financially Responsible Parties
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:
Registered Agent Information
Name Email Business Phone Mobile Phone
Charles McConkey [e-mail] 336-880-8764
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
941 Randolph Thomasville NC 27360 P.O Box 594 Denton NC 27239
Street
(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:
North Carolina Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street l City State Zip
EngineeringlConsulting Firm Information
Name Email Business Phone Mobile Phone
Jones Civil Design Mattp,JonesCivilDesign.com
Physical Address _ Mailing Address
Street 1 City State Zip Street 1 City State Zip
1019 Thornsby Matthews North 28105 1019 Thornsby Matthews North 28105
Lane Carolina Lane Carolina
q[14(Ztt

Additional Details
1. Stream Classification: C:Aquatic Life, Secondary Contact Recreation, Fresh water
2. Was Express Review Requested: No
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.