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HomeMy WebLinkAboutNCC215965_FRO Submitted_20211027FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION88V120U7 Noperson may initiate any land -disturbing activity on one or more acres as covered bythe Act before this form and anacceptable erosion and sedimentation uonbn| plan have been completed and approved by the Land {3ua|dx 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 inthe b|ank.) Part A. ��Brf'� ���|ar 1. Pn�ootNann Partin Solar ��� 2' Locatk>nof�nd-d)abud�nQaoUv�v:Coun ^^U�y �vorl�nwnahiElkin ��|k'nVV'|rf|'fe��o��d 3��"1��'1��6A"yJ �O'd��'03O2"�/ Highway/Street Longitude ~~ � 3. Approximate date land -disturbing activity U vityv�oonnn�enue:^ ASAP 4. Purpose ofdevelopment (neoidende].commercial, industrial, institutional, etc.). ����V °' �q � ���e�e�����u��en�(imd�i�o���0wand ��a��:~5 �1 1�� 8. Amount of fee enclosed: ^-' The Express Permitting application fee is o dual charge. The normal fee of$85.00 per acre is assessed without m ceiling amount. In addition, the Express Permitting supplement is� $250.00 per ocna up to eight acrem, after which the Erpnaea Permitting supplemental fee is a fixed $2.000.00 (Example: 9 nonee total is $2.585). NOTE: Both fees are rounded up to the next whole acre and need to be paid by separate checks to NCDENR. � 7. Has mnerosion and sediment control plan been �|ed? Yes No Enu\osn ^^ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Nam Steve [aV'Or E-mail Address GtGVlOr@depCo0OoVe['COD ��f�_�M�r_�1f�� |�Ui hJ/4 Telephone ~�~ ~~' ~'�~ {�eU#'`''^ Fox# '~^^ 9. Landowner(s) of Record (attach accompanied page to list additional owners): TaV|Oe Amy Et Al Name Telephone Fax Number 105 V8llBVbn3Ok Drive; PO BOX625 Current Mailing Address Elkin, NC 28621 City Current Street Address State Zip city Zip 1A�� 10. Deed Book No. '~~' Page No. 614 Provide acopy ofthe most current deed. Part B. 1. Company( or firm(s) 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 proplietorship, the name of the owner or manager may be listed as the financially responsible party. DEPCOM Power Inc. Name 9185 E Pima Center Pkmv#1AO Current Mailing Address E-mail Address Current Street Address Scottsdale AZ 85258 Scottsdale AZ 85258 City State Zip City 91 �RO-���O_��1O |e|*Pkon '-- —' - --'- Fax Number. 2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated North Carolina Agent: Timmons Group (Derrick Johnson, PE) Derrick.Johnson@timmons.com Name E-mail Address 5410 Trinity Road, Suite 102 5410 Trinity Road, Suite 102 Current Mailing Address Current Street Address Raleigh, NC 27607 Raleigh, NC 27607 City State Zip City State Zip Telephone (949) 866-4951 Fax Number (919)859-5663 (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: Corporation Service Company N/A Name of Registered Agent E-mail Address 2626 Glenwood Avenue, Suite 550 2626 Glenwood Avenue, Suite 550 Current Mailing Address Current Street Address Raleigh NC 27608 Raleigh NC 27608 City State Telephone 800-927-9800 Zip City State Zip Fax Number N/A (c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other consultant who can assist in providing any necessary information regarding the plan and its preparation: Timmons Group Engineering Firm or other consultant Jacob Dooley, PE Individual contact person (type or print) jacob.dooley@timmons.com E-mail Address 919-866-4937 N/A Telephone Fax Number 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. Type or print name Signature _ P s z-N I O/Z l'i L C �jZ�S/ice Title or Authority 9123 jZ/ Date HIJSTe a Notary Public of the County of State of North Carolina, hereby certify that C-1 EA04C MWO- , appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this _L3 day of S��i�, 20'2A ROBYN HEISTER Notary Notary Public -State of Arizona MARICOPA COUNTY # 582058 M commission expires © 3IM 15 � ZOZ1� Commission * 5, 202 y p Expires March 15, 2024