NCC233828_FRO Submitted_20240103

FINANCIAL RESPQNS|B|LITYAO9V0ERSH|PFORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Actbefore this form
and an acceptable erosion and sedimentation control plan have been oonop|ebad and approved by the Land
Quality Seotion, N.C. Department ofEnvironmental 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.
Pinnacle Storage �� �
|�D�� 6� ~�[�D"V
1� Project Name^ ' '
��U�['fU{�� �����[lr�V
2. Location of|and'dieturbing activity: County ^^ '` '^ City or Township ~^ "�
| |«� 1 ���� 30218O56 '75.869417
Highway/Street^�`� ' "" LaUtudom°c/ma/uen�em Longitude(ueu�o/ue»mem
�
3. AppApproximate date land-disturbing activity /1 /��1
vity will commence:"-' /'^--'
Commercial
|
~^[)DO[����|�.
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-ait 1�eburrowandwmnbaanaas)� '"--°`^D�
8. Amount of fee end 1�OO
oaod� � '~^°°'""DO
The application fee of$10O.00 per acre (rounded
uptothe next acre) is assessed without ceiling amount (Example: 8.10'acre application fee ia$900).
Checks should be addressed tuNCDEO.
7. Has an erosion and sediment control plan been filed? Yea[] Enclosed BRI No []
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
��������rf ��'<JF` robed��nobe�highdnve|opnnent.nono
Nome 'Robert' ^ High E-mail Address [e-mail]
/�1O\ �1/1�-7��7
Phone: Df�oe# \" '`^/ ' �" �-`�" K8obUe# \� '=/ -`-`" ' ^'"-'
Q. Landowner(s) of Record (attach accompanied page to list additional owners):
Robert & Oe|oris HamoU. Fred &Terry Suter 252-4/41-7887
Name Phone: C)ffice# Mobile#
���� �� 7�� �7O1 c� /� f ��
. ^� �^�J�{ , "° °, " . "� =PO��`�3� Hwy
Current Mailing Address Current Street Address
Nags Head 0= 2 959 Nags Head N= 27959
City State Zip City State Zip
~^-`
���^1 ���
10. Deed Book No. `� Page No."-' " Provide a copy nfthe most current deed.

ParkB.
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),
Pinnacle Storage of Grandy, LLr! FQbert@[Qberth.Ohd8veinpmenf.coOO
Company Name E-mail Address
324 Greenville Avenue same
Current Mailing Address Current Street Address
Wilmington NC 28403
City State Zip City State Zip
/��1�l\ ��y� ���M
Phone: O�ua# \" '"/ ^ `'�-�-`�° Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be distudaod, 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 tnconduct 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 oy the Registered Agent:
RQhertM_ High poberf(@rOberfh'ghdeVe|oU0Oent.com
Name of Registered Agent E-mail Address
324 Greenville Ave same
Current Mailing Address Current Street Address
Wilmington NC 28403
City State Zip City State Zip
/[�i[�\ ���_���D
Phone: D��a# \� '°/ ' "= °-`�= Mobile#
Name of Individual to Contact(if Registered Agent inacompany)
(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 nf Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual toContact(if Registered Agent is anompany)

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:
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 3 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 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.

Continued from Item Yin Part Bofthe Financial ' �� ��0u��
Attach � �
V 0
8�� ofb� p��g �3m9ede�&z ��� �n responsiblepa`' � —'' parties.
Company 2Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# NYobi|e#
Company 3Name E-mail Address -
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# yNobi|e#
Company 4Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# K8obile#
Company 5Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

(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 on 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 OBAName
The above information ia true and correct to the best ofmmy knowledge and belief and was provided
bynne under oath. (This form must be signed bythe Financially Responsible Person ifen|ndividua|(a)
or his attornay-in-fact, or ff not an individue|, by an oMioer, director, portner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). | agree to provide
co,naotaU information should there be any change in the information provided herein.
Robert M. High Registered Agent
Type or print name Title or Authority
's/��z�/�7��
Signature �� � � -// Date
|. q `�� . ^ mNotarypubUuof\heCounb/ oy Neo\ l�(AMV k/
U� -
State ofNo�h(�aroUna. hereby my�ifvthat ��� [k'/ appeared personally
before nne this day and being duly sworn acknowledged that the above form was executed byhino/har.
Witness rny hand and notarial seal, this day of M6 1
20 03
NOTARY PUBLIC Notary
NEW H'AN,'V COUNTY, NC
My commission expires