NCC216806_FRO Submitted_20211209

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 and/or fax information
unavailable, place NIA in the blank.)
Part A.
1. Project Name Lee Park Church Baseball Field
2. Location of sand -disturbing activity: County Union
City or Township Monroe
Highway/Street Morgan Mill Rd. Latitude 35.00867 Longitude-80.52169
3. Approximate date land -disturbing activity will commence: June 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Church Ball Field
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.0 Acres
6. Amount of fee enclosed: $ 325 . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jay Stikelea#her E-mail Address [e-mail]
Telephone [phone] Cell # 704-400-0117 Fax* N 1 A
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Tree Park Baptist Church
704-289-4674 N / A
Name
Telephone Fax Number
2505 Morgan Mill Road
2491 Morgan Mill Road
Current Mailing Address
Current Street Address
Monroe MC 28110
Monroe NC 20110
City State Zip
City State Zip
10. Deed Book No. 5380 Page No.
463 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 or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Lee Park Baptist Church
[e-mail]
Name
E-mail Address
2505 Morgan Mill Road
2491 Morgan Mill Road
Current Mailing Address
Current Street Address
Monroe NC 25110
Monroe NC 28110
City State Zip
City State Zip

Telephone [phone]
Fax Number N / A
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
/ A the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone,
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
Chrrs�vpAeY
Name of Registered Agent
';� 54 5 mor!,an hl,/J /_V.
Current Mailing Azfdress
Inonrce /VC ;7 �.//a
City State, / Zip
Telephone lay c;S*9- y& 77
Lcz d Zee {terr/c CA vrch . cnr
E-mail Address
,7-5-o.5- rl'Iar an Md J
Current Street Address
City State Zip
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 be signed by the Financially Responsible Person if an individual
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
rI-/'04-eN /,=Yla-
Type or print name
Signature
,,C-xecvfive Rajl'fd&r
Title or Authority
s- 4-1- c7oa I
Date
a Notary Public of the County of LLx�►
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness m
al, this 41�
day of ry'�ch_16 20 z►
->�A —ram
Notary
My commission expires -S