NCC223799_FRO Submitted_20221115

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1
Project Name SDA Sandhills Company
2. Location of land -disturbing activity: County Moore City or Township Cameron
Highway/Street Monroe rd Latltude(decimal degrees) 35.3400 Longitude(dedmai degrees) 79.315$
3. Approximate date land -disturbing activity will commence: 1012022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.7 acres
6. Amount of fee enclosed: $ 200.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed N No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Donald Berrong E-mail Address [e-mail]
Phone: Office#f Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Carolina Conference of Seventh Day Adventist Inc. 704-596-3200
Name Phone: Office #f Mobile #
P_Q. Box 44270 2701 E. WT Harris Blvd.
Current Mailing Address Current Street Address
Charlotte, NC 28215 Charlotte, NC 28213
City State Zip City State Zip
10. Deed Book No. 5847 Page No. 230 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Carolina Conference of Seventh Day Adventist Inc.
Company Name
P.O. Box 44270
Current Mailing Address
Charlotte NC 28215
City State Zip
Phone: office # 704-596-3200
[e-mail]
E-mail Address
2701 E. WT Harris Blvd.
Current Street Address
Charlotte, NC 28213
City State Zip
Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Chad Grundy
Name of Registered Agent
P.O. Box 44270
Current Mailing Address
Charlotte NC 28215
City
State
Phone: Office # 704-596-3200
[e-mail]
E-mail Address
2701 E. WT Harris Blvd.
Current Street Address
Charlotte, NC 28213
Zip City
Mobile # [phone]
State Zip
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
NIA
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Robert Nunnaley
Type or pr nt name
Signature
Muv, e kC i L�cS n ues
Lay Pastor
Title or Authority
? ! z -P zUzz
Date
a Notary Public of the County of
44 ,2 L
State of North Carolina, hereby certify that ?° 8,t d Nu vt 04.1appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 2q day of
EMA:Explres--.
THOMASpUBLi�Nolallorth Ca,....na ry
_..:..:._.._ _
My commission expires �� f

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record. -
N/A
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No_
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
NIA
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
NIA
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
N/A
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Boole No.
Page No.
Provide a copy of the most current deed.

Continued from item i in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed
to list all financially responsible parties.
NIA
Company 2 Name
E-mail Address
Current Street Address
Current Mailing Address
City State
Zip City State Zip
Phone: Office #
Mobile #
NIA
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
NIA
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
NIA
Company 5 Name
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State
Mobile #
Zip