NCC223302_FRO Submitted_20220921

FINANCIAL RESPKDNSIEBILITyNOWNERSHIPFORM
SEDIMENTATION POLLUTION CONTROL ACT
Noperson moyinitiabaany|and'disturbingmotivityonunonrmoremunaaaauoverodbyMheAo before this form
and an anoopbab|a erosion and sedimentation oonbp| plan have been completed and approved by the Land
Quality Seotion, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional OMiou. (Please type or print and, if the question is not epp|ioeb|a or the e-mail address or phone
number iounavailable, place N/A inthe blank.)
Part A.
1. Project Name cleazview Baptist Church
Vance 2. Location of land -disturbing activity: Count City orTmmnohi oeouernvu
Highway/Street nu-185 Boa Lahtudo(uomma/ouom°"31.3051 Long itude(*°"/m°/degrees) - 7 8. 4 4 5�
3. Approximate date land -disturbing activity will opnzz2 commence: ' �
4. Purpose of development (residential, commeroia|, industrial, institutional, etc.): church
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): r­9++ 3 3 1
8. Amount offee enclosed: «»« The application fee of$1UO.UVper acre (rounded
uptothe next acre) iaassessed without oceiling amount (Examp|o:8.10-aoroapplication fee io$8O0).
Checks should beaddressed toNCOE[).
7. Has anerosion and sediment control plan been filed? Yee[] Enclosed OD No O
O. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mai|Addren'
�azu o�oxeoa markuiokeoa47@vahoo uom
Phone: Office # 919.497'777* Mobile # [phone]
0. Landowner(s) of Record (attach accompanied page to list additional owners):
cloazview Baptist Cuuzru 252.438.8433 252.438.8433
Name Phone: Offioa# Mobile #
soau ns-zso annioeoo o°v s«ou na-zoa nooioeoa o,v
Current Mailing Address Current Street Address
Henderson mc 2753* oeouezuou mo 27536
City State Zip City State Zip
18. Deed Book No. 1218 Page No. 492 Provide acopy ofthe 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).
Clearview Baptist Church
Company Name
3485 US-158 Business Hwy
Current Mailing Address
Henderson NC 27536
City State Zip
Phone: Office # 252.438.8433
[e-mail]
E-mail Address
3485 US-158 Business Hwy
Current Street Address
Henderson NC 27536
City State Zip
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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
riY i r l(
Type or. rint n e Title or Authority
ignature Date
I, jDL a Notary Public of the County of rr (\,1(,u n
State of North Carolina, hereby certify that Mart : D i C6 n-!�- 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 �5*n day of (�� 20 cad
'.%g�a G Wopp!,�r Notary
Notary My commission expires
'OUb{1O

Continued from Items 9&YO/nPart Aofthe Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page eoneeded bulist 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 ocopy ofthe most current deed.
Landowner 3ofRecord:
Phone: OM1ce# Mobile #
Name
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide acopy ofthe most current deed.
Landowner 4ofRecord:
Phone: Office # yWubi|a#
Name
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide acopy ofthe most current deed.
Landowner 5ofRecord:
Phone: Offico# K4obi|e#
Name
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide acopy ofthe most current deed.