NCC220143_FRO Submitted_20220120

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-odisturbing activity on one or more acres as covered by the Act before This
farm and an acceptable erosion hand sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Depattment of Environment and Natural Resources. (Please type or print and, if
the question is not applicably or thre e-mail and/or fax information unavaiiabie, place N1A in fhe blanf�}
WA01
1. Project Names Slavic Kvangefic Church Site Developmerg
2- Locafian of fond -disturbing ;pctivity: County _Union & Ciiy or Township H h ridge, NC
Highway/Steet Ali!! GroveRoad Latitude ,,.N/A Langftude �N/A
3. Approyimate dale land-disWrblng aciivity will commence: _ Janua0'� �
4. Purpose of development (residential., commercial, industrial, instWfional, e#c.):institubona[
5. Total acreage disturbed or urrcavered. Cincluding vfF si#e borrow and waste areas), 6.28 Acres
fi. Amount of fee enclosed: $� 455.�a the app;�cafian fee of $65.00 per acre
grounded u� #a ire next ac�+e) is asses wi#hout a ceiling amount. (Example-: a 9-acxe �pp�icafivn fee
is $585)0
7- Has an erosion and sedimerit coRtrod plan been filed? Yes N Enclosed X
RN
Person to contact should erosion and sediment con�-�I issuers arise during lard -disturbing activity:
Nam � � E-mail Address � �� P � dt�� C�-M)4 1L. CDM�l
Telephone Call #7V 6pq7 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owner5j:
ielsfy 1pq SV
Name Talor►inrn� - •-- `- - -
Current Mailin
city
Address
AIC
State
0
2--.2o22.7000
zip
. �.�-ram. ��} �G �-au �vumaer-7 LAkPl.,e Li� a
city
Current i5t
diartio
10. Deed Book No.- Page No.
Part B.
et Address
Al Coo
Sate
24342Z-�-
Zip
Provide a copy of the most current deed.
Person(s) or firm(s) who are firtancially -responsible for the fond -disturbing
i#�
comprehensive list of afl respansle parties an an attached sheet):
�•1 ! r .ti r �-.
a�tivit�r(Provide a
S�,AV � C Crn.0 rC%i Gty�Q�ai,r�� U 00e � �%v►�1 I L
Name
Iff
rent Mailing
city
T9.0ir
dress
E-mail Address
"ni LA R te P,
Current Strek Address
CILr 0 AIC
Stafe Zip City State
Zip

T64ophone 70Y(to
irppmFax
Number
2. {a} If the FinanciallY ReSPOnOble Party is not a iicient 4f North CarotYna, gyre names and sVeet address
of the designated North Carona Agent:
SOT APPLICABLE
Name ail Address
Current Mailing Address
cfty gee Zip
Telephone
CU t Street Address
city Stake ZAP
Fax dumber
(b) ff the Financlafly Respon$-,Ue party is a Partnership or other person engaging in business under an
assumed name, attach a Cojpy of the Certificate of Assumed Name. If the Financially Responsible
P'arty is a Cowrabon, give nOme and street address of the registered Agent:
NOT APPLICABLE
Name of Registered Agent
Current Wiling Address
City Stage Zip
Telephone
E-mail Addmss
Current Street Address
Cfty State Zip
Fax Number
The above infoffilinallifion is true end correct to tie best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Pierson ff an individual
or his at#omey in-facl, or if not Ian individual, byan officer, director, partner,, or registered agent with
the authority to execute instr�ments for the Financially Responsible Person)., 1 agree to provide
corrected information should there by and change in the info ation provided herein.
Vh5l U
Yi r� �r�# name
r--
Signaiure
State of North Carolina, hereby c
personally before me this day'
executed by horn.
Witness my hand and notanl
Sea!
Tibe or Authority
Date
a Notary Public of the County of
ertify that NUSI\N
and being duly s
u111 Jill 1111 appeared
acknowledged that the above firm was
al{this day of r 20
Notary
My con
ission ex pines.
a