NCC223545_FRO Submitted_20221014

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 Name Hopewell Baptist Church
2. Location of land -disturbing activity: County Union City or Township Fairview
Highway/Street Concord Hwy _ Latltude(decimal degrees) 35.164 Longltude(decimal degrees)-80.540
3. Approximate date land -disturbing activity will commence: August 01, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): I nstitutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.84
6. Amount of fee enclosed: $ 800.00 . 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 Gregory Shaver
E-mail Address Gregory [e-mail]
Phone: Office # [phone]
Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hopewell Baptist Church Of Monroe [phone]
Name
Phone: Office # Mobile #
420 Hopewell Church
Road 8900 Concord Hwy
Current Mailing Address
Current Street Address
Monroe NC
28110 Monroe NC 28110
City State
Zip City State Zip
10. Deed Book No. 8463
Page No. 071 9 Provide a copy of the most current deed.
Deed Book No.7062
Page No. 0371
Deed Book No.5164
Page No. 0058

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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Hopewell Baptist Church Of Monroe [e-mail]
Company Name
420 Hopewell Church Road
Current Mailing Address
Monroe NC 28110
E-mail Address
420 Hopewell Church Road
Current Street Address
Monroe NC 28110
City State Zip City
Phone: Office # [phone] Mobile #
State
Zip
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:
Gregory Shaver [e-mail]
Name of Registered Agent E-mail Address
420 Hopewell Church Road 420 Hopewell Church Road
Current Mailing Address Current Street Address
Monroe NC 28110 Monroe NC 28110
City State Zip City State Zip
Phone: Office # [phone] 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 land 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). 1 I agree to provide
corrected information should there be any change in the information provided herein.
Gregory Shaver
President of Incorporation
Type print name Title or Authority
Sig tur Date
I, _�YutSU1 1C9�Y11f'> Notary County
L , a Nota Public of the Coun of Y1iC7n
State of North Carolina, hereby certify that
before me this day and being duly sworn a,
sy)wltf
the above form was
Witness my hand and notarial seal, this 'r(' day of 20,
Notary
My commission expi
2
personally
by him/her.