NCC216393_FRO Submitted_20211115

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 and/
or fax information unavailable, place NIA in the blank.)
Part A. MCA TRACK AND FIELD
1. Project Name
2. Location of land -disturbing activity: County U N I ON City or Township INDIAN TRAIL
Highway/Street INDIAN TRAIL-FAIRVIEW ROAD Latitude35 05' 1.41" Longitude-80 39' 12.09"
3. Approximate date land -disturbing activity will commence:AP RI L 2112021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): INSTITUTIONAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.44 AC.
6. Amount of fee enclosed: $455.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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:
NameRICK CALLOWAY E-mail Address rick.CaIIOWay(E-Mcit.Org
Telephone[phone] cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
FIRST BAPTIST CHURCH OF INDIAN TRAIL, NORTH CAROLINA 704-223-2 255 704-882-0631
Name Telephone Fax Number
P. O. BOX 2550 732 INDIAN TRAIL - FAIRVIEW ROAD
Current Mailing Address Current Street Address
INDIAN TRAIL NC 28079 INDIAN TRAIL NC 28079
City State Zip City State Zip
10. Deed Book No. SEE ATTACHED Page No. 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.
FIRST BAPTIST CHURCH OF INDIAN TRAIL, NORTH CAROLINA [e-mail]
Name
P.O. BOX 2550
Current Mailing Address
INDIAN TRAIL NC 28079
City State
Telephone[phone]
Zip
E-mail Address
732 INDIAN TRAIL - FAIRVIEW ROAD
Current Street Address
INDIAN TRAIL NC 28079
city QState
Fax Number704-882-0631
Zip

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
NA
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:
Julie James
Name of Registered Agent
P.O. Box 2550
Current Mailing Address
Indian Trail NC 28079
City
[e-mail]
E-mail Address
732 Indian Trail Fairview Rd.
Current Street Address
Indian Trail NC 28079
State Zip City
State Zip
Telephone [phone] Fax Number 704-882-0631
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.
Julie James
Type or print name
Treasurer
Title or Authority
71 s hoz.1
gnature Date
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L 1� 7��r 1 , a Notary Public of the County of 00'po
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowled
-
ged that the above form was
executed by him.
Witness my hand and q?jjFPl seal, this'Z3L' day of JJ Al
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NOTARY �� Notary
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My commission expires
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