NCC221402_FRO Submitted_20220411

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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. Midgard Self Storage Brevard NC, LLC, Sunshine Brevard LLC
1. Project Name g g
2. Location of land -disturbing activity: County Transylvania City or Township Rosman
Highway/Street 377 Old Rosman Hwy Latitude 35.165001 Longitude-82.808569
3. Approximate date land -disturbing activity will commence: February 25, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):' .5
6_ Amount of fee enclosed: $ 200 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Brooks
E-mail [e-mail]
Telephone [phone]
cell # 828-246-8400 NIA
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Midgard Self Storage Brevard NC, LLC, Sunshine Brevard LLC 770-609-8276
Name
Telephone Fax Number
1146 Canton Street
377 Old Rosman Hwy
Current Mailing Address
Current Street Address
Roswell, GA 30075
Rosman, NC 28712
City State
Zip City State Zip
10. Deed Book No. 992
Page No. 182 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.
Midgard Self Storage Brevard NC, LLC, Sunshine Brevard LLC
Name
E-mail Address
1146 Canton Street
377 Old Rosman Hwy
Current Mailing Address
Current Street Address
Roswell, GA 30075
Rosman, NC 28712
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 E-mail Address
Current Mailing 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
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.
Type or print name
Signature
lllnelL
Title or Authority
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Date
I, L� a Notary Public of the County of'�
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State o , hereby certify that ���_� appeared
personally beforg r g this day and being duly sworn cknowledged that the above form was
executed by him.
WoUtwl hand and notarial seal, this " day of % ��C 20 2,Z
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