NCC223356_FRO Submitted_20220927

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Willoughby Substation
1. Project Name
2.
3.
4.
5.
6.
7
0
Location of land -disturbing activity: County Union City or Township Monroe
Highway/Street 3405 Watkins Rd. Latitude 34.9961 Longitude-80.69722
Approximate date land -disturbing activity will commence: August 15, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial Utility
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.80
Amount of fee enclosed: $ 500 . 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).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Matt Baucom 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):
Union Electric Membership Corporation 704.289.3145
Name
1525 N Rocky River Rd
Current Mailing Address
Monroe NC 28110
City State
10. Deed Book No. 6625
N/A
Telephone Fax Number
1525 N Rocky River Rd
Current Street Address
Monroe NC 28110
Zip City
Page No. 812
State
Zip
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.
Union Electric Membership Corporation Matt. [e-mail]
Name
1525 N Rocky River Rd
Current Mailing Address
Monroe NC 28110
City
E-mail Address
1525 N Rocky River Rd
Current Street Address
Monroe NC 28110
State Zip City
Telephone [phone] Fax Number N/A
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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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:
6ne,qM, N-AIess
Name f Re istered Agent
157 2 S 1J E.)4, Rwe,( PU
Current Mailing Addres
IM«,rvc_ N C. W O
City State Zip
Telephone 70L} - IV, , 3ILK
M,n ' > ty W&N u7 L)0N wc1— N.&AC - CyN\
E-mail Address
Current Street Address
C ity
Fax Number
State Zip
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.
Gregory S. Andress
Typ r n nam
Signature
Executive Vice President and General Manager
Title or Authority
Date
I. A P_� S, , a Notary Public of the County of \Jf( k'L -)
State of North Carolina, hereby certify that G CQb(u S • evc�e55 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 day of—C� inel, 20 Q Z'-�_
ANGEL S. THOMPSON
NOTAFtyePPBLIC
Union County
State of North Carolina
My Commission Expires December 15, 2026
Nota
My commission expiresQeL