NCC241786_FRO Submitted_20240613

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 NameAdam Street Drainage Improvements
2. Location of land-disturbing activity: County Cumberland City or Township Fayetteville
Adam Street 35.0500 N 78.87 22 VI
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)._
3. Approximate date land-disturbing activity will commence: February 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Drainage
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2
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❑ Enclosed ❑x No ❑
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Byron Reeves E-mail Address [e-mail]
Phone: Office# 910-433-1301 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Fayetteville 910-433-1301
Name Phone: Office# Mobile#
433 Hay Street 433 Hay Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
10. Deed Book No. 9340 Page No.248 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).
City of Fayetteville [e-mail]
Company Name E-mail Address
433 Hay Street 433 Hay Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
Phone: Office# 910-433-1301 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:
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)
(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.
Byron S. Reeves Assistant Public Services Director
Type or print name Title or Authority
,(� 9/22/22
S gnatu ' N67-(
Date
yuh , a Notary Public of the County of C.u.., er)aN d
State of North Carolina, hereby certify that by re, S, Ze .•sreS 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 day of SefkeMber , 20 a-a-
Notary
.`` uNG y '%
• 0 r-vrj-.• My commission expires 13 7
2 '°LIB\>V .a,

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.
Praise Fellowship Church of God
Name Phone: Office# Mobile#
510 Adam Street 510 Adam Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
Deed Book No.7570 Page No 0568 Provide a copy of the most current deed.
Landowner 3 of Record:
Praise Fellowship Church of God
Name Phone: Office# Mobile#
510 Adam Street 515 Adam Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
Deed Book No.5724 Page No. 692 Provide a copy of the most current deed.
Landowner 4 of Record:
Praise Fellowship Church of God
Name Phone: Office# Mobile#
510 Adam Street 521 Adam Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
Deed Book No. 5262 Page No.68 Provide a copy of the most current deed.
Landowner 5 of Record:
Praise Fellowship Church of God
Name Phone: Office# Mobile#
510 Adam Street 523 Adam Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
Deed Book No.7265 Page No.729 Provide a copy of the most current deed.

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 6 of Record:
Praise Fellowship Church of God
Name Phone: Office# Mobile#
510 Adam Street 525 Adam Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
Deed Book No. 7547 Page No.27 Provide a copy of the most current deed.
Landowner 7 of Record:
Praise Fellowship Church of God
Name Phone: Office# Mobile#
510 Adam Street 527 Adam Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
Deed Book No.7691 Page No.323 Provide a copy of the most current deed.
Landowner 8 of Record:
Praise Fellowship Church of God
Name Phone: Office# Mobile#
510 Adam Street 529 Adam Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
Deed Book No. 7691 Page No.323 Provide a copy of the most current deed.
Landowner 9 of Record:
Praise Fellowship Church of God
Name Phone: Office# Mobile#
510 Adam Street 531 Adam Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
Deed Book No. 4947 Page No. 452
Provide a copy of the most current deed.

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 i oof Record:
Annie L. Moore
Name Phone: Office# Mobile#
519 Adam Street 510 Adam Street
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
Deed Book No.3913 Page No. 65 Provide a copy of the most current deed.
Landowner 11 of Record:
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.
Landowners 2 of Record:
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.
Landowners3of Record:
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.