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Home My WebLink AboutNCC231368_FRO Submitted_20230508 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 address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name Ramsey Street CCSS 2. Location of land-disturbing activity: County Cumberland City or Township Fayetteville Highway/Street Ramsey Street Latitude(decimai degrees)35.1183 N Longitude(decimai degrees)78.8814 W 3. Approximate date land-disturbing activity will commence: February 2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Self-Storage Facility 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.0 6. Amount of fee enclosed: $300.00 . 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). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes El Enclosed ® No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Russ Reinhart E-mail Address russ.reinhart( millervalentine.com Phone: Office#803-798-3800 Mobile# 9. Landowner(s) of Record (attach accompanied page to list additional owners): Manis Family, LLC Name Phone: Office# Mobile# PO Box 65029 716 Whitfield Street Current Mailing Address Current Street Address Fayetteville, NC 28306-1029 Fayetteville. NC 28306 City State Zip City State Zip 10. Deed Book No. 9868 Page No. 858 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 or if the landowner(s)is an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies). MV Commercial Construction russ.reinhart(a�millervalentine.com Company Name E-mail Address 823 Gervais Street. Suite 200 Current Mailing Address Current Street Address Columbia NC 29201 City State Zip City State Zip Phone: Office#803-798-3800 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: Corporation Service Company nick.johnson(c�millervalentine.com Name of Registered Agent E-mail Address 2626 Glenwood Avenue, Suite 550 Current Mailing Address Current Street Address Raleigh NC 27608 City State Zip City State Zip Phone: Office#513-774-8400 Mobile# Nicholas J. Johnson 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 E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# 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 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 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 Party). I agree to provide corrected information should there be any change in the information provided herein. Nicholas J. Johns Secretary— Registered Agent Type or -iiia Title or Authori y • /`1 Signature Date I, Mew i (ee - BirOW V1 , a Notary Public of the County of I1OIl nevi State of No( a, hereby certify that Iv 1 a_ 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 TC2V1 UC1 , 20 =� ti Notary • s" MARILEE F BROWN Notary Public My commission expires (0-'f a / 5 State of Ohio �� My Comm.Expires r %. o' December 12, 2025 Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: Manis Family. LLC Name Phone: Office# Mobile# PO Box 65029 716 Whitfield Street Current Mailing Address Current Street Address Fayetteville NC 28306-1029 Fayetteville. NC 28306 ' City State Zip City State Zip Deed Book No. 9219 Page No. 368 Provide a copy of the most current deed. Landowner 3 of Record: Newport Ramsey. LLC Name Phone: Office# Mobile# 4290 New Town Avenue 116 Park Lane Current Mailing Address Current Street Address Williamsbura VA 23188 Concord MA 01742 City State Zip City State Zip Deed Book No. 8868 Page No 864 Provide a copy of the most current deed. Landowner 4 of Record Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No Page No. Provide a copy of the most current deed Landowner 5 of Record Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed.