NCC223831_FRO Submitted_20221115

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 NIA in the blank.)
Part A. Atlantic Discount Storage
1. Project Name_ _
2. Location of land -disturbing activity: County OnsloW City or Township Sneads Ferry
Highway/Street N C 210 Latitude 35.5435 Longitude 77.4337
3. Approximate date land -disturbing activity will commence: August 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.3
6. Amount of fee enclosed: $ 195.00 . 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:
NameJohn L. Gurley
E-mail [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Lynda M. Uzzell
919-921-0079
Name
Telephone Fax Number
1600 E Walnut St
Same
Current Mailing Address
Current Street Address
Goldsboro, NC 27530-5242
City State Zip
City State Zip
10. Deed Book No. 588 Page No. 20
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 proprletorship,
the name of the owner or manager may be listed as the financially responsible party.
Atlantic Discount Storage, LLC
[e-mail]
Name
E-mail Address
PO Box 631
same
Current Mailing Address
Current Street Address
Pikeville, NC 27863-0631
City State Zip
City State Zip
252-578-1426
Telephone
Fax Number

2. (a) If the Financially Responsible Parry 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.
John L. Gurley
Registered Agent
Type or print name Title or Authority
gnature Date
a Notary Public of the County of
State of North Carolina, hereby certify that t3 L r appeared
personally before me this day and being duly sworn acknowlLddged that the above form was
executed by him.
Witness my nano anag&—YOM'is day of , 20 7�
Notary Public
Wayne Co., North Carolina
My Commission Expires Dec. 1, 2024
Notary
Seal
My commission expires IU4