NCC221695_FRO Submitted_20220503

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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 N/A in the blank.)
Part A.
1. Project Name Hubble Solar
2. Location of land -disturbing activity: County Columbus City or Township Whiteville
Highway/Street Vinson Blvd, NC 130 Latitude 34.300670 Longitude-78.709670
3. Approximate date land -disturbing activity will commence:
June, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Solar power facility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.2
6. Amount of fee enclosed: $ $3,500.00 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Justin Taylor E-mail Addressjustin.taylor@purepowercontractorE
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Charlie Formyduval
Name Telephone Fax Number
1603 Vinson Blvd.
Current Mailing Address Current Street Address
Whiteville, NC 28472
City State Zip City State Zip
10. Deed Book No. 225 Page No. 256 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
Pure Power Contractors, LLC [e-mail]
Name
2812 Gray Fox Road
Current Mailing Address
Monroe, NC 28112
City
E-mail Address
Current Street Address
State Zip City
Telephone [phone] Fax Number
State
Zip

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
NA
Name
NA
Current Mailing Address
NA
City State Zip
Telephone NA
CL1
E-mail Address
NA
Current Street Address
NA
City State Zip
Fax Number NA
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Crowley Professional Engineers, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Michael Crowley 919-626-6755
Individual contact person (type or print) 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 it 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.
Justin Taylor, Pure Power Contractors, LLC
Type or pri nam
Signature
Managing Member
Title or A thority
2 2oz
Dat
I,��, a Notary Public of the County of t�Y1
State of North Carolina, hereby certify that appeared personally
before me this day and being duly swom acknowledged that the abdVe form was executed by him.
Witness m�,,k�ttl'`d1�Atarial seal, this 7-3 day of 20�
�i'a,�), _ cAtvu
Notary
eal
My commission expires ZZ
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