NCC230229_FRO Submitted_20230131

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 Tri-County EMC - Pink Hill Substation
lin 1 Lenoir
2. Location of land -disturbing activity: County DupCity or Township SmithTo.Wp/Pink HIHTownship
West Pleasant Hill Road (SR 1105) 35.030998°-77.746607'
Highway/Street Latitude(deamal degrees] LOngltude(decimai degrees)
3. Approximate date land -disturbing activity will commence: January 9, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Electrical Substation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.00
6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑ No ❑x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameTCEMC - Tony Grantham E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
TRI COUNTY ELECTRIC MEMBERSHIP CORPORATION [phone]
Name Phone: Office #
P.O. BOX 130
Current Mailing Address
DUDLEY, NC 28333
Mobile #
4255 S U.S. 117 ALT HWY
Current Street Address
DUDLEY, NC 28333
City State Zip City State Zip
Duplin: 1998 Lenoir: 1947 Duplin:197 Lenoir: 246
10. Deed Book No. Page No. 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 orif the landowner(s) is
an individual(s), the names) of the owner(s) may be listed as the financially responsible partyfts).
TRI COUNTY ELECTRIC MEMBERSHIP CORPORATION [e-mail]
Company Name
P.O. BOX 130
Current Mailing Address
DUDLEY, NC 28333
E-mail Address
4255 S U.S. 117 ALT HWY
Current Street Address
DUDLEY, NC 28333
City State Zip City State Zip
Phone: Office # [phone] 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
business registry, give name and street address of the Registered Agent:
TRI-COUNTY ELECTRIC MEMBERSHIP CORPORATION [e-mail]
Name of Registered Agent
P.O. BOX 130
Current Mailing Address
DUDLEY, NC 28333
City
State Zip
Phone: Office # [phone]
J. Michael Davis
E-mail Address
4255 S U.S. 117 ALT HWY
Current Street Address
DUDLEY, NC 28333
City State Zip
Mobile #
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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State 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 information provided herein.
Tony Grantham
Type or print narge
5ignatu�re
Manager of Engineering and Operations
Title or Authority
1412P�rz-
Date
I, �LJI� u�Yih �1 +� I , a Notary Public of the County of
State of North Carolina, hereby certify that dYW U 16 OWIVI 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 a5 day of , 20 0a0_
90��4►tl� Notary
NOTARY t q aDa�
My commission expires
PUBLIC
\co���

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip