NCC231791_FRO Submitted_20230609

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 N/A in the blank.)
Part A.
1. Project Name Siecinski Self Storage
2. Location of land-disturbing activity: County Harnett City or Township: Barbeque
Highway/Street Barbeque Church Rd Latitude(decimal degrees) 35.3795°N Longitude(decimal degrees)79.1072°W
3. Approximate date land-disturbing activity will commence: May 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):_commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.0
6. Amount of fee enclosed _$350 . 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mike Wilkes E-mail Address mwilkes1959(asgmail.com
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Kenneth Siecinski 910-813-7022
Name Phone: Office# Mobile#
166 Bailey Thomas Road
Current Mailing Address Current Street Address
_ Sanford, NC 27332
City State Zip City State Zip
10. Deed Book No. 3511 Page No._0605 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).
Kenneth Siecinski vwbuq94( yahoo.com
Company Name E-mail Address
166 Bailey Thomas Road Same
Current Mailing Address Current Street Address
Sanford, NC 27332 Same
City State Zip City State Zip
Phone: Office# Mobile# [phone]
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 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)
(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 engagingi under
n business under an assumed name, give name eral
which the company is Doing Business As. If the Finan ' is an individual, Gen
Partnership, or other company not registered and Financially Responsible Party ch a copy
of the Certificate doing business under an assumed name, atta
of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the eng ration:
consultant who can assist in providing any necessary information regarding the plan and its pre
ineer or other
pa
LPK Consulting, PA JLi ka LPK-Consultin corn
Engineering firm or other consultant E-mail Address
John Lipka 336-945-0302 704-936�?406
Individual contact person (type or P }rint 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 bytheFinanciallyResponsible Person if an individual(s)
or his attorney-in-fact, or if not an individual,9 officer, por registered agent with
Y by an director, partner, provide
the authority to execute instruments for the Financially Responsible Party). I agree to
corrected information should there be any change in the information provided herein.
eCI L, S* S -'elri)(1--abli\
Type or print name Title or Authority
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Signature Date
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a, n , a Notary Public of the County of L6G-
u_S of North Carolina, hereby certify that v\ � QGI'
�� 1 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
this 12 �dayof ` C� , 20 �-
Witness my hand and notarial seal,
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•` r��� '.,� Notary
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