NCC232221_FRO Submitted_20230727

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may ntbate any land-disturbing activity on one or more acres 35 covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 perrrst, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Oualcy Section, N.C. Deparimrnt of Environmental Oualiy. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question a not app$cable or the a-maul address or phone
number es unavailable, place WA in the dank.)
Part A.
1 F4prta Name Life Storage - Kannapotis
project :n o►vvs Amencan Rescue /".an «ct (..RPAJ lunar :rst the Project Nara below
under►vh'clr yflu applied far funding L'r:augh tote Llvision of Wafer::&as'rudure(DUYi)
2 land-disturbing of landsturbing activity_ County Cabarrus city or Township ta
Biscayne Drive �s.cuu'a eor6.r�
Nrghway;Sbect lnOtudc,,.. r7..K, Longrtudc,rn...„eve„
3. Approximate date landdsturbing activity will commence*7/24/2023
4. PL.-pose of development(residential.commercial,indtmtrial, irntearbonal.etc-):Commercial
5, Total acreage di,turbed or uncovered(Including oh site borrow and waste areas)'7.20
6. Amount of ire enclosed 5800 The application fee of 5100 00 per acre(rounded
up to the nest acre)is assessed without a ceding amount (Example.8.10acre applicabon fee a 5900).
Checks should be addressed to NCDEC.
7 Has an erosion and sediment control plan been filed? Yes❑ Enclosed Q No ❑
8 Per:on to contact should erosion and sediment control *-.iucs arise during land drstu!bIng act.-y
Nano.Jamie Rolewicz m„1 Addrtz.;[e-mail]
Phone. ott>ce a 704-905-0335 Mobde s 704-905-0335
9 Landowner(s)of Record(attach accomprndbd page to Ir-.t udd.tonal ovri.rt)
Legacy Po,nte Concord, LLC 704-905-0335 704-905-0335
Name Phu Oiticc• Mobile
19354 Watermark Dr. Suite 102 19354 Watermark Dr Suite 102
Current MaTng AddreTz Current Street Address
Cornelius. NC 28031 Cornelius, NC 28031
Crty State Lp City State Zp
10 Ovcd Book No 16516 page No 247 Provide a ropy of the most current deed

Part EL
1. Company(ies)who arc financially responsible for the land-ctsturbng activity(Provide a comprehensive list
of al responsible parties on accompanied page.)If the company rr a sate p opleforship oritVie l&rtsa.smer(s)o
an individuals, The nametsl of lor the owners)may be ksfcd as thy fnancla7y resporu le partyfresl.
Legacy Pointe Concord, LLC jamie@rolewicz_com
Company Namc F ma1 Addict: - -
19354 Watermark Dr. Suite 102 19354 Watermark Dr. Suite 102
Cu:rcnt fAaiTing AdJ+C�. Current Street Addre-.;
Cornelius NC 28031 Cornelius NC 28031
City State Zip City State Zip
Phone: Ot"ce: 704 905 0335 i,tob.ie 8 704-905-0335
Note' I1 the Financially Responsible Party is not the owner of the land to be disturbed,include with this form
the landownef's signed and dated writ en consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land d*turbing activity
2 (a)If the Financially Responsible Parry is a domestic company re,stcved on the NC Secretary of State
bus.ne s registry,give name and street address of the RcQrtercd Agent-
Laura S. Temple [e-mail]
Name of Registered Agent E-mai Addre_ts
19354 Watermark Dr. Suite 102 19354 Watermark Dr. Suite 102
Current Mating Address Current SU cct Address
Cornelius NC 28031 Cornelius NC 28031
City State Zip City S;.ttr Zip
phone Office• 704-905-0335 Afobcc 704-905-0335
Laura S. Temple
Nary,.,or Individual to Contact(if Registered Agent is a cornpurty)
(b) lithe Financially Responsible Party is not a resident of Notch Carolina,give name and strict address
of the designated North Carolina agent who is registered on the NC Secretary of State business registy.
Na Na
Name of Rigs;.tered Agent E.Itned Address
Na Na
Current Mailing Addrer.r. - _ Current Street Address
Na Na
City rF Zip City State Zip
Phone. Office>: n/a fr1obs c a n/a
Na
Name of tndnridual to Contact(if Registered Agent r:a company)

(c)lithe Financially Rewonsbtc Party is cngagvtg in bu..less under an assumed name, give name, under
which the company iv Doing BuTsz ess As. If tie Financially Re+.ponsibte Party rs an individual. Genera!
Partnershp,or other company not re1istered and cluing txrsonro:urxict on a.::umcd name,attach a copy
Of the Certificate of Assumed Name.
C00tpiny SBA Name
The above information is true and correct to the best of my knowwledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsbte Person if an indrvidual(s)
or his attomey-inT fact, or if not an individual, by an officer, didor, partner, or registered agent with
the authonty to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change In the Information provided herein
Jamie M. Rolewicz Manager
Ty p name Title or Authority
nature Dale
1. Laura S Temple , Notary PubIc of me County of Iredell
State of North Carolina.hereby cervy that Jamie M. Rolewicz, Manager appeared personally
before me this clay and being duty sworn acknowledged that the above form was executed by himlher
'rVtness ►ny hand and notarial seal, this 2-1 da'y 0` July . 2023
``a�nt11I u/444,
Clo!ay
J NotarvPtbte ce
lredar My commKn expires 1128127
County
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Corrhnued from t:ems 9 & 10 in Part A of the Financial RespornibrIrtyO4wner hrp Form for mut p'ee
owners Attach copies of this paage as needed to 1/St all landowner
Lusidowncr 2 of Record.
Name Phone Office S f.!cbi:c*
Current MaTing Address Current Street Address
City State by City Smote Zip
Occd Book No Page No Provide a copy of the rnoa current deed
Landowner 3 of Record:
Name Phone: Office t Mob de d
Current Malting Address Current Street Address
City Stale Zip City State L,p
Deed Book No. Page No Provide a copy of the most current deed_
Landowner 4 of Record:
Name Phone: Offices Mobile t
Current Wring Address Current Sti ect Addr c5.5
City State Zip City State Zip
Deed Book No _ Page No. Provide a copy of the most current deed
Landowner 5 of Record-
Namc Phone: Offices fob lc>y
Current Modell)Address Current Street Address
City State ZIP City State Zip
Deed Book No_ Paw No. Provide a copy of the most current deed

Conenued from Item 1 in Part B of the Financral Rosponsibrlr'tyROwnorship Form for muthpe parrs
Attach copes of this page as needed to list all hnancially responsible ponies
Company 2 Name E mein Address - --
Current Using Address Current Street Address
City State Zip City Sta:c Zip
Phone Oflke! Mobde•
Company 3 Name E-mail Address
Current',Raking Address Current Street Address
Cry State Zp CO.? Sta:c Zip
Phone (rice I Mobile
CorTpany 4 Name E•maii Mdre
Current Mainfl Addres Cunent Street Address
City Slate Zip City Sate Tap
Phone: (Noce s Mobile•
Company S Name E-mad Address
Current Mailing Address Current Street Address
City State Zip City State Zrp
Phone: Office! Mobile