NCC222749_FRO Submitted_20220803

III......
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT 9
No person may initiate any land -disturbing activity on one or more acres as covered N.the-,4 before this
form and an acceptable erosion and sedimentation control plan have been completed and approv
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. Sneads Ferry Presbyterian Church
1. Project Name ry y
2. Location of land -disturbing activity: CountyOnslOW City or TownshipSneads Ferry
Highway/Street NC 210 Latitude 34d33'25.82" Longitude 77d26'46.18"
3
4
5
6
Approximate date land -disturbing activity will commence:JUly 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.61
Amount of fee enclosed: $ 300 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900,00).
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 Barbara Donaldson E-mail [e-mail]
Telephone [phone]
Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Sneads Ferry Presbyterian Church, Inc. 910 327-0166
Name
P.O. Box 759
Telephone Fax Number
776 NC HWY 210
Current Mailing Address Current Street Address
Sneads Ferry, NC 28460 Sneads Ferry, NC 28460
City State
10. Deed Book No. 3893
Zip City
State
Zip
Page No. 583 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.
Sneads Ferry Presbyterian Church, [e-mail]
Name to '� k' L,\ p s .C- .— I,-\—
P.O. Box 759 `'S f \-
Current Mailing Address
Sneads Ferry, NC 28460
City
State Zip
E-mail Address
776 NC HWY 210
Current Street Address
Sneads Ferry, NC 28460
City
Telephone [phone] Fax Number
State
Zip

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
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
State
E-mail Address
Current Street Address
Zip 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.
Barbara Donaldson
.- or print
Signature
Clerk
Title or Authority
Date
I, a Notary Public of the County of 01VI4,0 _.>
State of North Carolina, hereby certify that 11..r6ni-. appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this __�_ day of 44ew , 20 - -9—
Thomas Geohagan
NOTARY PUBLIC -- •—c•
onslow Caulity Notary
Seal Hgrth Carolina
My Commission Expires March 04 2025 My commission expires / vG ��/� V 20,-�;