NCC222993_FRO Submitted_20220825

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 Rebekah Evans 230kV POD
2. Location of land -disturbing activity: County_Cumberland City or Township Grays Creek
Highway/Street
Up +tLatltUde(decimal degrees) LOngltude(decimal degrees) on Tyson Rd-78.834739 34.931081
3 Approximate date land -disturbing activity will commence: 06/24/2022
4 Purpose of development (residential commercial industrial institutional, etc.): Utility Substation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4
6. Amount of fee enclosed $ 400 The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example 810-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
Na m Pathan Bass (Pike Engineering LLC) -Em a it [e-mail]
Phone Off ice# 803-835-7929 Mobile# [phone]
9
Landowner(s) of Record (attach accompanied page to list additional owners):
South River Electric Membership Corporation 910.892.8071
Name Phone: Office #
PO Box 931 17494 US 421 S
Current Mailing Address Current Street Address
Dunn, NC 28335 Dunn, NC 28335
City
State
10 Deed Book No. 11389
Zip City
Page 059 1
State
Mobile#
Zip
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).
South River Electric Membership Corporation
Company Name
PO Box 931
Current Mailing Address
Dunn, NC 28335
City State Zip
Phone: Off ice# 910.892.8071
[e-mail]
E-mail Address
17494 US 421 S
Current Street Address
Dunn, NC 28335
City State
Mobile#
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:
Chris Spears
Name of Registered Agent
PO Box 931
Current Mailing Address
Dunn, NC 28335
City State Zip
Phone. Office# 910.892.8071
[e-mail]
E-mail Address
17494 US 421 S
Current Street Address
Dunn, NC 28335
City
Mobile#
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
City State
Phone: Office#
t-man Haaress
Current Street Address
Zip City State Zip
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 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) I agree to provide
corrected information should there be any change in the informatign provid herein.
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Type or int game Title or Authority
<�&- J0,,�r ) v ,;?-02-7
Signature Date
a Notary Public of the County of
State of North Carolina, hereby certify t h a t ""� 5 C`C--' !�, 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 __j�..day of �� �2 0 2 Z _
V��"�' NI.—
Kacey W Johnson
Notary Public Notary
Harnett County, NC My commission expires