NCC230956_FRO Submitted_20230404

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one nr more acres as covered by the Act. including any
activity under a common plan of development of this size As covered by the NCr01 permit, 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 rs not applicable or the e-mail address or phone
number is unavailable place N/A in the blank )
Part A.
1 Project Name Raeford Road Self Storage
•
Location of land-d*.t.l-h1-I0 activity CourvtY Cumblerand City or Township
Raeford Road 35.04' -78.9`
tlphwev!St ree' Let+tUdl?to a-.a y x. • : Longitude(d.KlmAt dWmPq,
kr)proxtmatc_ date land-dtr:.t,1-;ing ac1tvrty will commence 5.1 .23
4 Pu,;,r. o' Oevei;rrne-r -eF.tde-alai cor rr efc:a: ;r.1:,5!7.<, atonal. etc , Commercial
otom i:' ri9J: llia•1' IC+: ;r' jnccvered j r.C . r; Ou-S:",e. d,i, and waste areas) 2.5
f= Amount a' tc_.c cr•t:;tosrc 5 3007 • i:.. , - , fee of$100 00 per acre i rourded
1( .: thtr. ncic a ce .. : 3 10-acre application fee is $9001
,:tiyc : sthoutc t,: aaa-c::se_ lc.NCDEQ
' sr erosia :s I:. let 1t"1er control plan been fied? Yes ❑x Enclosed (S3 No ❑
t Pei-sor t: :;Omy:`. a'tuut'_ r.`t>:,tc,• a-1c st.cirnent COMM? issues arise during land-disturbing activity
,skii,,,K Andrew Mericle Address d [e-mail]
,e,s 8042401911
IOvvV1 '6 if f1c.'_s'C at a_' y ?_r"I� ICJ. rG�yC 5I c_';''I ��I Owners)
VG Fayetteville Storage LLC 305.428.6504 205.478.0234
tea+'ire c c Mi3O,le
2601 S Bayshure Dr STE 1720 2601 S Bayshore Dr STE 1720
:.JI fait•. I0allllit frj0icc.0 • c --
t✓ilarrli FL 33133 Miami FL 33133
Il _+tQ(C 16. 1`. J ib Zip
L 11560 0443
_ JCCC bucii Iv_ Mbye vduJla III 111061 _aired( Jeier.l.

Part B.
1 Cnmpprwf ipcl who Arp fir r loll\ rc pr r il'.1P 4(yr two IAr'd d' tii htnq artivity(F'rnvirle a Compro_hAngivp Iht
of All rf.', I1hnCihlp hRrlipC t,h Qr r ll',A^'iafl (1a p } N!hp C r/7'00any r.<A.<rYi4 n''rltWliefVY•4hrC1 nr'f ffta(�I1Ifr7WYfOr(.QI i.
Rn rnrlry rlimirc 1 //it nAmp(c 1 n!fhr -,r,•.c rngl•he` lic!n,H At flvP le'146r740!y r$,API'YP14111e p4yy17a4l
VG Fa\vetteville Storage LLC [e-mail]
i•nmham /4PrrIP Add*ese
2601 S Bayshore Dr STE 1720 2601 S Bayshore Dr STE 1720
t.ilrreri MAihh� larlrl�ae C: -o- oc{ Addrec� - -
Miami FL 33133 Miami FL 33133
hit\ State tic C � State Zip
nhrinc. (')fll. c 305 428.6504 yn�¢ .o# 205.478.0234
Not 1h; r rlah:lali\ C:�:;t.1^ 1`11c ''a", `a ^,t,^,� ^f!'•€, 'arid to be disturbed. include with this form
!}x. OnrInwr)r : :AI)ha: I'lr 'lalar v' 1``u r. c ' submit a draft erosion and sedirnentation
..1•Cl pi?' 'ir t: +•1:1.I:.' "Ip :4-1'1-1,-J`G-
a } !tut Inan:;lln 4.pg4,rr!:.0.-,lr :1—, - - r•. - j :,n the NC Secretary of State
hiso.K4: replxt•t ),vc •131^1p .to," •r.r' . .. . . . . . . .-. ,
IJre . i• ..
::i!\ :i die
rc :/ttiUt;x I,I
Iha�rc :) I,iC) v lil;.d !: :.u!Ily:" r t\Chil:iicr •• 3 -.i•1-a1
1. I. lire r li,a,r.ial , 1.1. a CAi.IC, ',,III••a
)' 1!,e Ue:ly ldlei IV•.1111 ..ti,:llo.a aya 1 �.'1. c Ii ic1 a: 1 c 'J.. :c1 7i.a1 f aiiirc GI.:311•a_c .tji (I1i
r•cylcic•c
tL1GI1. Wir..1114 .� .. z+;.7 ..:1 a3.4
II .1;NIC /Ir I., �iiJI V'r"Ii .)111-.c
1•401.1c 1' 1�1111.LII.t1 I ::A, I ,.1�4.. . . . . . -I....

(c) If the r inencielly Responsible f'Arty is Pr'gaq,rq +n hUa ^Ads angler an a44„merl name, give name under
which the cornrianv is f)oino Rucir,Pcc As if the f!rA";•a"y Fte4rnn4file Party 14 an inrlivirlual general
Pertnerchip or either Cr'mpery 1r,1 'CQ,cterP(1 R"11!!",_^.(1 h:,s-^044 it-`rlor an a4411m,rl name attach a copy
of the Cprtifirete of Aci!mPr1 Njwme
ornrAnv 11RA hierne
the above information is trip And correct to the hest of my knowledge and belief and wnwas provider]
h\ rnr i inclpt oAth (Thic form must he s►gnpd by the rinancially, Responsible Person if an individual(s)
`11- at1.7 nrv-in-fprt Or if nrtiAn indtveduAi by Ain officer director. partner, or registered agent with
the authority tr c.ro,.tic i-,strumptYtg f(yr the FuNanicialty Respon cihle Party) I agree to prr)v1r1e
corrected inforrnat,n- r_`r,',,ii.-' `hare hp 8riy oNanicte in the information provided herein
_ cv print name - tie or Authority
.-4. A. f
.i._1!, ., \ :... .
'ne County of M.a"^n ^4-4...
`•Malt: : iro..e#.- ..--.!w.1. ,,r,'r,-,, _r...n . _ ,_r'r,' t1V ` ., ;,;�.. appeared personally
tvff:r: r- : ?h,: :1.2k a-i: .`rr,,-r; i.:•, .N.- .- , t,orrn was executed by him/her
lrl'it'1Cij= 1`11 i:1'IC :4'1' '1:1'..,•,.. ..r, ., • V. 3 a. , .,.t . 20 �HC�.
, Jf
1st! ,aiJ(1 oxprrrc-i ,w r -' ) ` -
, r J M1` . /C!C S�
. t+..-, !... h.wr •ads. .ad..►Ar.
i