NCC221563_FRO Submitted_20220422

FINANCIAL RESPONSIBILITY/OWNERSHIP 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.
1. Project Name Callaway Self Storage Warehouses Site Plan
2. Location of land -disturbing activity: County Surry City or Township Mount Airy
Highway/Street North Andy Griffith Parkway (US Hwy 52)
Latitude 36.525856 Longitude-80.626844
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc): Site grading for commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.25 +/- acres
6. Amount of fee enclosed: $ 400.00 . The application fee of $100.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $900). Checks should be
addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes No_X_ Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tom Webb E-mail Address mayberrypropertiesa-msn.com
Phone: Office # 336.786-2388 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Callaway ARD, LLC
Name
1203 W. Lebanon Street
Current Mailing Address
Mount
City
NC 27030
State Zip
336.786.2388
Phone: Office # Mobile #
Same
Current Street Address
Same
City
State Zip
10. Deed Book No. 1787 Page No. 1025 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 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).
Callaway ARID, LLC
Name
1203 W. Lebanon Street
Current Mailing Address
Mount Airy NC 27030
City State Zip
Phone: Office # 336.786-2388
mavberrvoroDertiesamsn.com
E-mail Address
Same
Current Street Address
Same
City State Zip
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)

(0 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 Financial 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 or his attomey-
in-fact, or if not are individual, by an officer, director, partner; or registered agent with the authority to
execute instruments for the Financiaiiy Responsible Person]. I agree to provide corrected information
should there be any change in the information provided herein.
Tom Webb _ Member Man er
Type or print name Title or Authority
lam_
Signature Date
I, a Notary Public of the County of _ 'I lJ� ti GA,
State of �€xa, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by
him.
Witness my hand and notadaI seal, this U day of t , 20
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Seal My commission expires 0 f 0
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January S. 2024
No. GG 943993
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