NCC215589_FRO Submitted_20211028

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 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 and/or
fax information unavailable, place N/A in the blank.)
Part A. Magnolia Hill Storage Facility
1. Project Name g g y
2. Location of land -disturbing activity: County Moore City or Township Carthage
Highway/street Hwy NC 22 Latitude 35.264319 Longitude -79.413922
3. Approximate date land -disturbing activity will commence: 1 1 /1 /21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commerical
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12
6. Amount of fee enclosed: $2,780 . 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 James B. O'Malley E-mail Address [e-mail]
Telephone cell # 414-573-0855 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Carthage NC Self Storage, LLC 414-573-0855
Name Telephone Fax Number
35 Martin Dr. Same
Current Mailing Address Current Street Address
Whispering Pines, NC 28327 Same
City State Zip City State Zip
10. Deed Book No. 5446 Page No. 474 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Carthage NC Self Storage, LLC [e-mail]
Name
35 Martin Dr.
E-mail Address
Same
Current Mailing Address Current Street Address
Whispering Pines, NC 28327 Same
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
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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
Current Mailing Address
City
State Zip
E-mail Address
Current Street Address
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:
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Engineering Firm or other donsultant
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Individual contact person (type or print)
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E-mail Address
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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.
James B. O'Malley Member
e or print name Title or Authority
7/r� %znza
Signat a Date
a Notary Public of the County of MC>c>r C_
State of North Carolina, hereby certify that P5 ' Me-L0 appeared personally
before me this d2x,,agg,being duly sworn acknowledged that the above form was executed by him.
Witness m r` rand n&deal, this VLk day of C�`--` �� , 20 2
Notary
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+A My commission expires IL 2 a
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