NCC215578_FRO Submitted_20211028

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 acceptablperosion and sed,imentaboa, control I in have .been completed and approved by
the
o *
appropriate i"submit the completed form to the
Q
ea
a - i "on a I ty'pe 0 r`
ase print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A.
BED C
1. Project Name THEL BAPTIST CHURCH
2. Location of land -disturbing activity: County F-' ROBESON City or Township LUMBERTON
Highway/Street SR 2033 (HORNETS RD) Latitude 34.642837 Longitude -78.973005
3. Approximate date land -disturbing activity will commence: SEPTEMBER 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc,): COMMERCIAL RELIGIOUS
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.0 AC
19-
6. Amount of fee enclosed: T�_ _. The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example.- a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity-,
Name LARRY W. ANDERSON E-mail Address [e-mail]
Telephone [phone] Cell# 910-608-2808 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BETHEL BAPTIST CHURCH, INC. 910-736-1356
Name Telephone Fax Number
130 CANECUTTER ROAD 130 CANECUTTER ROAD
Current Mailing Address Current Street Address
LUMBERTON, NC 28358 LUMBERTON, NC 28358
City State zip City State Zip
10. Deed Book No. 2206 Page No. 783 Provide a copy of the most current deed.
Part B.
1 Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company orfinn is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
JOSEPH WEST
Name LJ-mail Address
130 CANECUTTER ROAD
Current Mailing Address
LUMBERTON, NC 28358
City
State
Telephone9lO-736-1356
Ne
Current Street Address
LUMBERTON, NC 28358
Zip City State Zip
Fax Number

2. (o) If the Financially Responsible Party is not resident of North Cmro|ino, give name and street address
of the designated North Carolina Agent:
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is o Partnership or other person engaging in business under an
assumed nomn, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party iaoCorporation, give name and street address ofthe Registered Agent:
Name ofRegistered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone.
Fax Number
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 he signed by the Financially Responsible Person if an individual
or his aftorney-in-fact, orifnot an individua|, by an offioer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). | agree to provide
corrected information shnu|dthonebe any change iOthe information provided herein.
(OSEPHBVEST
p or print name
Inature
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Title or Authority
1 0 1W a Notary Public of the County of
State of North Carolina, hereby certify that Tro"h tGeLt, appeared
personally before me this day and being duly swdrn acknowledged that the above form was
executed by him.
Witness my hand an Lday of 20_oA_L4___
Seal '