NCC221854_FRO Submitted_20220518

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 and/
or fax information unavailable, place NIA in the blank.)
Part A. Oak Solar - Substation
1. Project Name
2. Location of land -disturbing activity: County Northampton/Halifax City or Township N/A
Highwav/Street NC Hwy 46 Latitude 36.5071518 Longitude-77.7998853
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Solar Power
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16 ac
6. Amount of fee enclosed: $ 1,600 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900,00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nicholas Tillson E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Lewis Belmont Properties LLC
Name Telephone Fax Number
PO Box 768 PO Box 768
Current Mailing Address Current Street Address
Jackson NC 27845 Jackson NC 27845
City State Zip City State Zip
10. Deed Book No. 1006 Page No. 512 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.
Oak Solar, LLC [e-mail]
Name E-mail Address
192 Raceway Drive 192 Raceway Drive
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 flame. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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.
Kenny Habul Manager
Type or print name Title or Authority
z
Signature Date
------------------------------------------------------------------------------------------------------------------------------------
[, daa Notary Public of the County of ti jpi C )
ereby certify that 1� te'"Igq 1 Vl---_---- appeared
personally before me this day and being duly sworh acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 10 day of , 20.2
Notary
Seal
My commission expires hion) s®. 2-02.5
0
Carolyn auf;er�-.>,
Notary Public-Cor
MY Corn miss.CO Fnr;e Ctio.,
April3a, xpires
2025

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