NCC230592_FRO Submitted_20230307

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. Apex Solar
1. Project Name
2. Location of land -disturbing activity: County Cleveland City or Township Unincorporated
Highway/Street Pony Barn Road Latitude 35.423839 N Longitude-81.479622 W
3. Approximate date land -disturbing activity will commence: June 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar Energy
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Tripp MCSwain E-mail Address [e-mail]
Telephone__ _ Cell # 704-457-7004 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jean Yancey Elliott
PID: #71199 Name Telephone
P.O. Box 191
Current Mailing Address Current Street Address
Fallston NC 28042
City State Zip City State
10. Deed Book No. 18 Z
Page No. 639
Fax Number
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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Pine Gate Renewables [e-mail]
Name E-mail Address
130 Roberts Street 130 Roberts Street
Current Mailing Address Current Street Address
Asheville NC 28801 Asheville NC 28801
City State Zip City State Zip
Telephone [phone] Fax Number

CONTINUATION OF LANDOWNER(S) OF RECORD
Landowner(s) of Record (attach accompanied page to list additional owners):
Name
Road
Current Mailing Address
Telephone
Current Street Address
Fax Number
City. M State
Zip
City
State Zip
PID:
#35585
Deed Book No. 1645
Page No.�
1922
Provide a copy of the most current deed.
#35587
Deed Book No. 1473
Page No.
2200
Provide a copy of the most current deed.
#35586
Deed Book No. 1233
Page No.
111 _
Provide a copy of the most current deed.
Landowner(s) of Record (attach accompanied page to list additional owners):
Leon D. Leonhardt & �resa M
Name
Telephone
Fax Number
P.O. Box 580
-
Current Mailing Address
Current Street Address
Fallston NC
28042
_
City State
Zip
City
State Zip
PID:
#59529
Deed Book No.
Page No._
Provide a copy of the most current deed.
#35649
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner(s) of Record (attach accompanied page to list additional owners):
Leon D
Name Telephone
P.O. Box f
Current Mailing Address Current Street Address
Fax Number
Fallston
NC
28042
City
State
Zip
City
State Zip
PID:
#35642
Deed Book No.
1212
Page No.
2122
Provide a copy of the most current deed.
#35641
Deed Book No.
1624
Page No.
1760
Provide a copy of the most current deed.
#35644
Deed Book No.
1212
Page No._
2122
_ Provide a copy of the most current deed.
Landowner(s) of Record (attach
accompanied
page to list additional
owners):
Name Telephone Fax Number
_O. Box 5817
Current Mailing Address Current Street Address
Fallston NC 28042
City State Zip City State Zip
PID: #57509 Deed Book No. 1388 _ Page No. 1456 _ Provide a copy of the most current deed.

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 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 Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
State
E-mail Address
Current Street Address
Zip City State Zip
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.
Type or print name
7�7
Sig ature
C6n
Title or Authority
y. Is. 2d
Date
1, COfi nhk- WWI l; r, .,a Notary Public of the County of _! yr Covv%6Q ,
State of North Carolina, hereby certify that &\ CA- 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 L_ day of AV"1 2024
CcO� wM,ssioN.
ci 6i Ft y ' Nota
S,iI NoZ
.gRy ,�,, =
G ..�, PUBLIC �; V ` My commission expires 'A l
�'' CBE CO��.�`•