NCC220116_FRO Submitted_20220126

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Thermal Belt Outreach Ministry,Inc.
1. Project Name
2. Location of land -disturbing activity: County Polk City or Township Columbus
Highway/Street Hope Valley Lane Latitude 35.25034 Longitude-82.20543
3. Approximate date land -disturbing activity will commence: upon approval
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.65 Acres
6. Amount of fee enclosed: $130.00 . 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 'P
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Odom, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 828-429-4355 Fax # N/A
E
Landowner(s) of Record (attach accompanied page to list additional owners):
Thermal Belt Outreach Ministry, Inc. 828-894-2988
Name Telephone
P.O. Box 834 134 White Drive
Current Mailing Address Current Street Address
Columbus NC 28722
City State Zip
Columbus NC
City
State
828-894-0130
Fax Number
28722
Zip
10. Deed Book No. 369 Page No. 391 Provide a copy of the most current deed.
Part B. and Deed Book No. 438 Page No. 1119
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.
Thermal Belt Outreach Ministry, Inc. [e-mail]
Name E-mail Address
Current Mailing Address
Columbus NC
city
134 White Drive
Current Street Address
28722 Columbus NC 28722
State Zip
City
State
ME
Telephone [phone] Fax Number 828-894-0130

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name 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 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:
Margot B. Cater [e-mail]
Name of Registered Agent E-mail Address
P.O. Box 834 134 White Drive
Current Mailing Address Current Street Address
Columbus NC 28722 Columbus NC 28722
City
State Zip
Telephone [phone]
City State Zip
Fax Number 828-894-0130
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.
Margot B. Carter
Executive Director
Type or print name Title or 7th�ri]ty r
Signature Date
I, f, „rU,.,_ , a Notary Public of the County of 2o
State of North Carolina, hereby certify that R.?!:: appeared
personally before me this day and being duly orn acknowledged that the above form was
executed by him.
Witness and rtl 0hal seal,
Notary Public :
Polkc0linl_
MY CommE
2 07- P.
O 27-202x3
CrA IR Cam\
this �-�day of 'Dtc_. , 20 3" 1
ota
My commission expires _7