NCC223636_FRO Submitted_20221031

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 NIA in the blank.)
Part A.
1. Project Name REMC Lowesville to S Denver Transmission Line Pro. # LINCO-2022-007
2. Location of land -disturbing activity:, County Lincoln City or Towns hip Catawba Springs
Highway/Street N Pilot Knob to N Little Egypt 35.453973-81.005910
Latftude(declmal degrees) Longitude{dechal degrees)
-
I Approximate date land -disturbing activity will commence:July 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): electrical infrastructure
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 44,34
6. Amount of fee enclosed: $ previously included
The application fee of $100.00 per acre (rounded
_ up to -.the next acre) is assessed withouLa. ceiting_amo.unt_(Example: 8-1-0-acre-application fee-is-$900)..
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes [)x` Enclosed ❑ No
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJudson B. Wortman E-mail [e-mail]
Phone: Office#• Mobile # [phone] ext 416 828-245-1621 ext 416
9. Landowner(s) of Record (attach accompanied page to list additional owners):
see attached spreadsheet
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
see attached see afitache 10. Deed Book No. Page No, d_ Provide a copy of the most current deed.

Fart 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 names) of the owners) may be listed as the financially responsible party(ies).
Rutherford Electric Membership Corporation
Company Name
PO BOX 1569
Current Mailing Address
Forest City NC 28043
City State Zip
Phone: Office # 1-800-521-0920
[e-mail]
E-mail Address
186 Hudlow Road
Current Street Address
Forest City NC 28043
City State Zip
Mobile # [phone]
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
_ busine_ssregistry,_give n.ame-and-str_eet_add.ress._of the -Registered Agent:
Elizabeth T. Miller
Name of Registered Agent
PO Box 1569
Current Mailing Address
Forest City NC 28043
City State Zip
Phone. Office # 828-286-8222
NA
[e-mail]
E-mail Address
186 Hudlow Road
Current Street Address
Forest City NC 28043
City State Zip
Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
(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:
NA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # 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.
NA
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 information provided herein.
Colon L. Saunders
Tyge or print name
-S
Signature
V.P. of Operations
title or Authority
Date
a Notary Public of the County of G
State of North Carolina, hereby certify that C0104 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
14
Witness my hand and notarial seal, this l L _ day of (june, 20 -:2—,-
Notary
My commission expires
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Property Owner
Easement Reference
L S M J PROPERTIES LLC
Db 3076 Pg 888
HAGER ORABELL N HEIRS OF
Db 3151 Pg 341
CLARK ANITA JOAN
Db 3090 Pg 188
TIM NORMAN PROPERTIES LLC
Db 3044 Pg 869
STTR LIMITED PARTNERSHIP
21 SP 141
RIVERWALK DENVER II LLC
Db 3094 Pg 683
LINK LANDING DENVER LLC
Db 3126 Pg 641
WAL MART REAL ESTATE BUSINESS TRUST
Db 3127 Pg 918
WAL MART STORES EAST LP
Db 3127 Pg 927
CHIPT CHARLOTTE LINCOLN EAST LLC
22 SP 029
CHIPT CHARLOTTE LINCOLN WEST LLC
22 SP 027
EAST LINCOLN LAND CO INC
Db 3166 Pg 917
VENTOSA LLC
Db 3166 Pg 912
JOHNSON DALTON B JR and JOHNSON LINDA B
Db 3119 Pg 434
EAST LINCOLN LAND CO INC
Db 3166 Pg 921
TURNER CRAIG ALLEN and TURNER DENISE L
Db 3102 Pg 939
HUNTER BRENDA TRIVETTE
Db 3099 Pg 885