NCC233547_FRO Submitted_20231201

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Head Start Childcare Facility Replacement
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Projec_
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Cumberland City or Township Fayetteville
Highway/StreetDeep Creek Rd Latitude(decimaldegrees) 35.0419 LongitUde(decimal degrees)-78.8544
3. Approximate date land-disturbing activity will commence: 1 1/01/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Educational
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.8
6. 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Daniel Barney E-mail Address [e-mail]
Phone: Office# 910-354-2826 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Cumberland Community Action Program Inc. 910-485-6131
Name Phone: Office# Mobile#
PO Box 25759 4525 Campground Rd
Current Mailing Address Current Street Address
Fayetteville NC 28314 Fayetteville NC 28314
City State Zip City State Zip
10. Deed Book No. 9387 Page No. 0591 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).
Action Pathways, Inc. [e-mail]
Company Name E-mail Address
PO Box 25759 4525 Campground Rd
Current Mailing Address Current Street Address
Fayetteville NC 28314 Fayetteville NC 28314
City State Zip City State Zip
Phone: Office# 910-485-6131 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:
Lonnie Ballard [e-mail]
Name of Registered Agent E-mail Address
PO BOX 25759 4525 CAMPGROUND RD
Current Mailing Address Current Street Address
FAYETTEVILLE NC 28314 FAYETTEVILLE NC 28314
City State Zip City State Zip
Phone: Office# 910-485-6131 ext 1601 Mobile#
LONNIE BALLARD
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.
LONNIE BALLARD CEO
Ty e or print na Title or Authority
/// // 1
Si ture Dat
I, ph t • iloYp0. "h , a Notary Public of the County of 0-IY1toel kn 4
State of North Carolina, hereby certify that L p,hh l 4J Q 6-01,`4 appeared 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 to day of Li , 20 2.S
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Notary
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November 3, 2023
DENR
Re: Letter of Consent for 328 Deep Creek Rd, Fayetteville, NC 28312
To Whom It May Concern,
I, Lonnie Ballard, consent that Action Pathways, Inc., can perform land disturbing activities at 328 Deep
Creek Rd, as required.
The parcel,0447-30-2240,was purchased under the previous legal name, Cumberland Community
Action Program, Inc.,which has since been legally changed to Action Pathways, Inc.
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Lon i Ballard
O
On this_day of November, 2023 before me,the undersigned Notary Public, personally appeared
Lonnie Ballard, proved through satisfactory evidence of Identification,which were drivers
and acknowledged.
X N G,; t 6rea-1-1,
Notary Public Signature
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