NCC215174_FRO Submitted_20210914

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Yadkin Valley Self Storage, LLC Addition
2. Location of land -disturbing activity: County Surry City or Township Elkin
HighwaylStreet CC Camp Road Latitude 36.281684 Longitude-80.824738
3. Approximate date land -disturbing activity will commence: July 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.54 acres
6. Amount of fee enclosed: $ 260+1000 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. 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 Mark Colbert E-mail Address [e-mail]
Telephone [phone] Cell # 336-469-2162 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Yadkin Valley Self Storage, LLC 336-469-0799
Name Telephone
PO Box 589 639 CC Camp Road
Current Mailing Address Current Street Address
Elkin NC 28621 Elkin NC
City State Zip City State
Fax Number
28621
Zip
10, Deed Book No. 01605 Page No. 0285 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Yadkin Valley Self Storage, LLC benemastin@gro ail, com
Name E-mail Address
PO Box 589 639 CC Camp Road
Current Mailing Address Current Street Address
Elfin NC 28621 Elkin NC 28621
City State Zip City State Zip
Telephone [phone] _ Fax Number

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
Current Mailing Address
E-mail 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 State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Blue Ridge Environmental Consultants [e-mail]
Engineering Firm or other consultant Email Address
Justin C. Church, PE 336-844-4088 336-609-7726
Individual contact person (type or print) Telephone Fax Number
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.
Michael Wilson
Type or print name
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Signatu
Member
Title or Authority
✓ -- lC,7 �
Date
a Notary Public of the County of
State of North Carolina, hereby certify that 1 iC;_Si1&4 -tk appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and
10?*6 day of
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