NCC223559_FRO Submitted_20221103

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 NameDoor of Hope - Phase 1
2. Location of land -disturbing activity: County POI k City or Township M i I I Spring
Pea Ridge Road 35.297508 Lon Rude decimal degrees)_82.W6972
Highway/Street Latitude(decimal degrees) g (
3. Approximate date land -disturbing activity will commence: 8/1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5.
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9
6. Amount of fee enclosed: $900 . 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 ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameDave Stoltzfus
Phone: Office #
E-mail [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Door of Hope Ministry, Inc
Name
Phone: Office # Mobile #
P. O. Box 321 1710 Lynn Road
Current Mailing Address Current Street Address
Lynn, NC 28750 Columbus, NC 28722
City State Zip City State Zip
10. Deed Book No.468 Page No. 1 100-1109 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).
Door of Hope Ministry, Inc
Company Name
P. O. Box 321
Current Mailing Address
Lynn, NC 28750
City State
Phone: Office #
[e-mail]
E-mail Address
1710 Lvnn Road
Current Street Address
Columbus, NC 28722
Zip 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:
Jason L. Schlabach
Name of Registered Agent E-mail Address
0 x S, I I 1 Lvinp
Current Mailing Address Current Street Address
L,\In(\ � . Qx7�b (Il A maAS IBC
Cit State Zip City State Zip
Phone: Office #S� 9. 39,- 001 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 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.
e r f7a At 0 -%62,y
Company DBA ame
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.
Type or pr. t name
gnature
Title or Authority
G-/-zZ
Date
I, dwn( S-K Oblffiw , a Notary Public of the County of ?''C \y-
State of North Carolina, hereby certify that &'pYA 01MCAMCIV\ 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 %3j xf 1D , 20
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