NCC222225_FRO Submitted_20220616

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 HWY 181 STORAGE UNITS
2. Location of land -disturbing activity: County BURKE City or Township MORGANTON
Highway/Street_ 11195 sT MARY'S CHURCH RD Latitude 35.7684 Longitude-81.7445
3, Approximate date land -disturbing activity will commence: 06121/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.6
6. Amount of fee enclosed: $` $200 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900),
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael A Brown E-mail Address appstatetimbers@gma➢t.com
TelephoneY Cell # _ 828-773.2157T Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
TruWest LLC 828-773.2187
Name Telephone Fax Number
400 Center Court Drive 400 Center Court Drive
Current Mailing Address Current Street Address
Boone, NC 28607 Boone, NC 28607
City State Zip City State Zip
10. Deed Book No. 002610 Page No. 00466 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.
TruWest Ll_C [e-mail]
Name — E-mail Address
400 Center Court Drive
Current Mailing Address
Boone, NC 28607
City State
400 Center Court Drive
Current Street Address
Boone, NC 28607
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
Oily 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
Current Mailing Address
City state Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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 A Brown owner - TruWest LLC
Type or print name Title or Authority
06/07/2022
Sign tore Date
I, I C , a Notary Public of the County off
State of North Carolina, hereby certify that V, i, V-\ appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this _day of 20 oZ�
Not ry
t •. < ENNE I H HICKS
�t ..:
Notary Public My commission expires
Watauga Co., North Carolina p
My Commission Expires Nov. 28, 2026