NCC230314_FRO Submitted_20230207

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate a 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 Environment, Health
and Natural Resources. (Please type or print and, if question is not applicable, place N/A in the
blank).
Part A.
1. Project Name Ample Storage
2. Location of land -disturbing activity: County Nash County
City or Township Rocky Mount , and Highway/Street Halifax Road
3. Approximate date that land -disturbing activity will be commenced: January
4. Purpose of development (residential, commercial, industrial, etc.) Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.96 AC.
6. Amount of fee enclosed $ 250.00
7. Has an erosion and sedimentation plan been filed? Yes No
Enclosed X
8. Person to contact should sediment control issues arise during land -disturbing activity.
Name Richard R. Herring, PLS Telephone [phone]
9. Landowner(s) of Record (Use blank page to list additional owners):
Turtle Run, LLC
Name(s)
PO Box 608
Current Mailing Address Current Street Address
Smithfield NC 27577
City State Zip City State Zip
10. Recorded in Deed Book No. 3227 Page No. 225
Part B.
1. Person(s) or firm(s) who are financially responsible for this land -disturbing
activity (Use a blank sheet to list additional persons or firms):
Turtle Run, LLC
Name(s)
PO Box 608
Current Mailing Address Current Street Address
Smithfield NC 27577
City State Zip City State Zip
919-343-3041
Telephone Telephone

2. (a) If the Financially Responsible Party is not a resident of North Carolina give name and
street address of a North Carolina Agent.
Name
Current Mailing Address
City State Zip
Telephone
Current Street Address
City State Zip
Telephone
(b) If the Financially Responsible Party is a Partnership or other person engaging
business under and 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
Registered Agent.
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
Current Street Address
City State Zip
Telephone
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, an officer, director,
partner or registered agent with 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
A-41A I
Signat re
Mar a.�ec, 1 ,An L.LL
Title or Authority
ti--I-11
Date
I, L A.- r-t 1 L, n sam ', o, G S , A Notary Public of the County of 1 c ��• �,•� 7S�
State of North Carolina, hereby e ify that Cry u L.C,.w, (per__ j c-
appeared personally before me this day and being dul}-�worn acknowledged that the
above form was executed by him.
Witness,ELh'�� qd notarial seal, this _day of NUV , 20�
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