NCC230634_FRO Submitted_20230314

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
3.
4.
5
6.
7
L,
Project NameCommunity Baptist Church
Location of land -disturbing activity: CountyChatham City orTownshipSiler City
Hamp Stone Rd 35.744038-79.487252
Highway/Street Latitudetaa�im�i degrees) Longitude(decimai degrees)
Approximate date land -disturbing activity will commence: J u ly 1st, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.) Religious Assembly
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3
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-acre application fee is $900).
Checks should be addressed to NCDEQ.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJosh Smith E-mail Addressjosh.smith3l @ymail.Com
Phone: Office # 91 9-742-3968 Mobile #
Landowner(s) of Record (attach accompanied page to list additional owners):
Community Baptist Church of Sller City, Inc. 91 9-742-3968
Name Phone: Office #
2575 Hamp Stone Rd Same
Current Mailing Address
Siler City, NC 27344
Current Street Address
City State Zip City
10. Deed Book No. 1 854
Page No.629
State
Mobile #
Zip
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).
Community Baptist Church of Siler City, Inc.
Company Name E-mail Address
2575 Hamp Stone Rd
Current Mailing Address
Siler City, NC 27344
Current Street Address
City State Zip City State Zip
Phone: Office # 91 9-742-3968 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:
Lois Lynch
Name of Registered Agent
17935 US Hwy 64
Current Mailing Address
Siler City, NC 27344
City
State Zip
Phone: Office # 91 9-673-3134
�)frl,ce cp�_o,6c.sile`c q. co
E-mail Address \ +
2-1-lb VQarveve
Current Street Address
5)��
City State Zip
Mobile#
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:
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.
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.
Lois Lynch
Type or Tint name
7 ;_2eVzL__
Signature
Registered Agent
Title or Authority
PZO,-2 Z
Date
--------------------------------------
I, 1_4a L�a� , a Notary Public of the County of ftC hrY
State of North Carolina, hereby certify that L 1 s L ncr) appeared personally
before me this day and being duly sworn acknowledged t [[ the above form was executed by him/her.
Witness my hand and notarial seal, this �� day of -�]� t +�.1� , 2 - Z
LELA I- PARTIN
A'o otary
we y
IC
�hatlham C ulnty 2oZ3
North Carolina My commission expires
L
Commission
ExplMr. ✓August 6, 2023

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
Name Phone: Office # Mobile #
Current Mailing Address
City
Deed Book No._
Landowner 3 of Record
Name
Current Mailing Address
City
Deed Book No._
Landowner 4 of Record:
Name
Current Mailing Address
City
Deed Book No._
Landowner 5 of Record:
Name
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
_ Page No. Provide a copy of the most current deed.
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.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #