NCC232422_FRO Submitted_20230816

Check if this project is ARPA-funded ❑
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_Browns Creek Baptist Church New Church Project
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Yancey City or Township_Burnsville
Highway/Street_3898 Hwy 80 S Latitude(decimaldegrees)0.35.855247N_Longitude(decimaldegrees)082.199341 W_
3. Approximate date land-disturbing activity will commence: March, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.269
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 David Michael Blevins E-mail Address_blevinsconstruction©yahoo.com_
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Browns Creek Baptist Church
Name Phone: Office# Mobile#
_3898 Highway 80 S _29 Lower Browns Creek Road
Current Mailing Address Current Street Address
Burnsville NC 28714_ Burnsville NC 28714_
City State Zip City State Zip
10. Deed Book No. 632 Page No. 267 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).
_Browns Creek Baptist Church
Company Name E-mail Address
_3898 Highway 80 S 29 Lower Browns Creek Road
Current Mailing Address Current Street Address
Burnsville NC 28714 Burnsville NC 28714_
City State Zip City State Zip
Phone: Office# 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:
David Michael Blevins [e-mail]
Name of Registered Agent E-mail Address
_5060 highway 80 S 29 Lower Browns Creek Road
Current Mailing Address Current Street Address
_Burnsville, NC 28714 _Burnsville, NC 28714_
City State Zip City State Zip
Phone: Office# Mobile# [phone]
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 attomey-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.
_David Michael Blevins-Oc-v4d,N k'cke1 1ev:''S Registered Agent
Type or print name Title or Authority
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Signature Date
e.lAvrt
art $ , a Notary Public of the County of•
State of North Carolina, hereby certify that DAN h teginaoBste4 VA 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 _ 20 25
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