NCC230720_FRO Submitted_20230317

1('N�41 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Henry Gibson Solar
2. Location of land -disturbing activity: County Scotland City or Township NA Highway/Street Henry Gibson Road Latitude(dedmalde®�eg) 34.778 Longitude(dBpmatdegrees) 79.570
3. Approximate date land -disturbing activity will commence: February 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar Farm
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 40.10
6. Amount of fee enclosed �6i 100 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
Has an erosion and sediment control plan been filed? Yes ❑x Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing. activity:
NameTom Michaud E-mail [e-mail]
Phone: Office # 904-710-8614 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
JAMES HOWELL COUGHENOUR 910-276-3091 910-276-3091
Name
208 Fulton Ave
Current Mailing Address
Laurinburg, NC 28352
city
10. Deed Book No. 886
Phone: Office # Mobile #
Current Street Address
State Zip city State Zip
Page No. 299 Provide a copy of the most current deed.
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Part S.
t . 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 nama(s) of the owner(s) may be listed as the financially responsible party(ies).
United Renewable Energy, LLC
Company Name
410 Peachtree Parkway Suite 4245-67
Current Mailing Address
Cumming, GA 30041
City State Zip
Phone: Office # 678-881 -0014
AP@u-renew,com
E-mail Address
1230 Samples Industrial Drive, Suite 100
Current Street Address
Cumming, GA 30041
City State Zip
Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this fort
the landowners 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:
Keith Herbs
Name of Registered Agent
1880 Adare Drive
Current Mailing Address
Clemmons, NC 27012
City State Zip
Phone: Office # 878-881-0014
[e-mail]
E-mail Address
1880 Adare Drive
Current Street Address
Clemmons, NC 27012
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 Meiling Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Sun Studio Inc.
Engineering firm or other consultant
Kevin Gorman
Individual contact person (type or print)
[e-mail]
E-mail Address
704-574-7631
Phone: Office #
Mobile #
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 individuals)
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. -
Amber Penland
Type gr print na e
Signature
Executive Vice President, Operations
Title or Authority
1119/23 t)9,oq.,23
Date 040 -"
j • � e rt� , a Notary Public of the County of /YJ ,.C%„w
State of North Carolina, hereby certify that e „ 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 ,__day of e u c , 20 02 3
MiCHE�ROBBRJ10
N PtlBt.tC
Madison County
North CarolitUe
My Cotmnisafon �cpfres
(*/,L,LQa,76&�6
Nbtary
My commission expires Dz 0'7a0912

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 a8 landowners.
Landowner 2 of Record:
Rodney Parker
Name
15083 Saint Johns Church Road
Current Mailing Address
Gibson, NC 28343
[phone] 910) 217-2680
Phone: Office # Mobile #
Current Street Address
City state Zip City State Zip
Deed Book No. 976 Page No. 240 Provide a copy of the most current deed.
Landowner 3 of Record:
Ellis Covil
Name
8041 Gibson Rd
Current Mailing Address
Gibson, NC 28343
910-232-2538
Phone: Office #
Current Street Address
910-232-2538
Mobile #
City State Zip City State Zip
Deed Book No. 1075 Page No. 114 Provide a copy of the most current deed.
Landowner of Record:
Name
Current Mailing Address
City State Zip
Phone: Office # Mobile #
Current Street Address
City State Zip
Deed Book No, Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Current Mailing Address
Phone: Office #
Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed,