NCC221598_FRO Submitted_20220504

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or mo`b,,,gcres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan Eve been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (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 Grace One Church
2. Location of land -disturbing activity: County Union ` ffy:or TAnship Matthews
Highway/Street2609 Chestnut Lane Latitude 35d-03'40.72"N Longitude 80d-43113.74"W
3. Approximate date land -disturbing activity will com
4
Dec 1 2018
Purpose of development (residential, commercial, industrial, institutional, etc.): Church
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
5.20
6. Amount of fee enclosed: $ 390 . 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 Haohsin Huang E-mail Address haohsinh@graceone charlotte org
Telephone
Cell# 704-989-2278 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Charlotte Grace One Christ Church 704-980-9264
Name Telephone Fax Number
2609 Chestnut Lane
Current Mailing Address Current Street Address
Matthews NC 28104
City State Zip City State Zip
10. Deed Book No. 6995 Page No. 699 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Charlotte Grace One Christ Church, Inc haohsinh@graceonecharlotte. org
Name
2609 Chestnut Lane
Current Mailing Address
Matthews NC 28104
City State Zip
Telephone [phone]
E-mail Address
2609 Chestnut Lane
Current Street Address
Matthews NC 28104
City State Zip
Fax Number

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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
(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:
Name of Registered Agent
Current Mailing Address
E-mail 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 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.
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Type or print name Title or Authority
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Signature Date
I,VN PA ,'t 0Ch& r- , a Notar y Public of the County of
State of North Carolina, hereby certify that n &'A).4HNJ appeared
personally before me this day and being duly sworn acknowledg d that the above form was
executed by him.
Witness my,bandian4notarial seal, this q day of 2 n', 6e-(- �, 20 _
EN A.
NOT,q,Q .yam,
m : Not ry
f LIC My commission expires � a20l
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