NCC224012_FRO Submitted_20221205

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Lake Valle Mini- Storage
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street Lake Valley Drive Latitude(dedmWdegrees) 35.0842 Long itude(dedmal degrees) -78.9666
3. Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.60
6. Amount of fee enclosed 500 + $1,250 = $1,750. The Express Permitting application fee is a dual
charge. The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which
the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is
$2,900). Checks should be addressed to NCDEQ.
CI!
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed Z No 9
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bob Avriett E-mail Address bobs-truongprop.com
Phone: Office # 910-850-1041 Mobile #_____
Landowner(s) of Record (attach accompanied page to list additional owners):
Truong Properties, LI_C.
Name
2543 Ravenhill Drive Ste C
Current Mailing Address
Fayetteville NC 28303
City State Zip
910-850-1041
Phone: Office #
2543 Ravenhill Drive Ste C
Current Street Address
Mobile #
Fayetteville _ NC 283.03
City State Zip
10. Deed Book No. 11538 Page No. 0890 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible paity(ies).
Truong Properties, LLC.
Company Name
2543 Ravenhill Drive Ste C
Current Mailing Address
bob(1truonoorop_com
E-mail Address -
2543 Ravenhill Drive Ste C
Current Street Address
Fayetteville NC 28303 Fayetteville NC 28303
City State Zip City State Zip
Phone: Office # 910-850-1041 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
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially 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
(d) If 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:
Moorman Kizer & Reitzel Inc.
Engineering firm or other consultant
James M. Kizer Jr. PE
Individual contact person (type or print)
kizerjr mkrinc.com
E-mail Address
910484-5191
Phone: Office #
Mobile #
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(s)
or his a y-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the thori to execute instruments for the Financially Responsible Party). I agree to provide
cerrrecte 'nformation should there be any change in the information provided herein.
U
ignature
Manager
Title or Authority
14 o ,Z Y
Date
I, Cynthia M. Smith , a Notary Public of the County of Hoke
State of North Carolina, hereby certify that Robert Avriett appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her,
Witness my hand and notarial seal, this day of Q_ 20��
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Notary
My commission expires pZ�