NCC230955_FRO Submitted_20230404

WinslowWetsch, pllc
attorneys at law
416 Morson Street Joyce L. Davis(1948-2006)
Raleigh, NC 27601
Tel [phone] Everette P.Winslow
Fax [phone] [e-mail]
Laura J.Wetsch
[e-mail]
March 23, 2023
(VIA EMAIL: [e-mail] & U.S. MAIL)
Ms. Lyn Hardison
Environmental Assistance and SEPA Coordinator
North Carolina Environmental Quality
943 Washington Square Mall
Washington, NC 27889-3532
RE: Roanoke Electric Cooperative & Ahoskie ERC Proposed Utility Easement
Dear Ms. Hardison:
Please find enclosed the signed Financial Responsibility/Ownership Form with respect to the
above-referenced matter.
If you have any questions, do not hesitate to contact us.
Sincerely,
WINSLOW WETSCH, PLLC
Ails/tk7-Pf?CtlY1,
Loretta Moss
Legal Assistant
Enclosure
Employment Law • Nonprofits • Cooperatives • Corporations • Contracts • Business Disputes
Insurance Disputes • Discrimination/Harassment/Retaliation Claims • Wage & Hour/OT Claims

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 N/A in the blank.)
Part A.
1. Project NameAhoskie ERC 230 kV Transmission Line
2. Location of land-disturbing activity: County Hertford City or TownshipAhOSkIe
S R-1108 36.301430 -77.025793
Highway/Street Latltude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:Mar-2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.3
6. Amount of fee enclosed 1 ,400 . 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.
7. Has an erosion and sediment control plan been filed? Yes❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameMichael Ferguson E-mail Address [e-mail]
Phone: Office# 252-209-2229 Mobile# NA
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Piedmont Natural Gas Company INC NA NA
Name Phone: Office# Mobile#
550 S. Tryon Street Thomas Tract
Current Mailing Address Current Street Address
Charlotte NC 28202 Ahoskie NC 27910
City State Zip City State Zip
10. Deed Book No.000842 Page No.002 1 3 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 or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Roanoke Electric Membership Corporation [e-mail]
Company Name E-mail Address
PO Box 1326 518 NC Hwy 561 West
Current Mailing Address Current Street Address
Ahoskie, NC 27910 Aulander, NC 27805
City State Zip City State Zip
Phone: Office# [phone] Mobile# NA
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:
Roanoke Electric Membership Corporation
Name of Registered Agent E-mail Address
416 Morson Street 416 Morson Street
Current Mailing Address Current Street Address
Raleigh, NC 27601 Raleigh, NC 27601
City State Zip City State Zip
Phone: Office#NA Mobile# NA
NA
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 NA
Name of Registered Agent E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Phone: Office# NA Mobile# NA
NA
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
(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:
Booth & Associates, LLC [e-mail]
Engineering firm or other consultant E-mail Address
Dolores Hong [phone] x 125 NA
Individual contact person (type or print) 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 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.
Marshall Cherry CEO
Type or pr' t nam Title or Authority
3l a3
Signature aa/aoDate
I, re. M.oSS , a Notary Public of the County of Wake
State of North Carolina, hereby certify that M ct-'s141,\ C-hsz-rP appeared personally
before me this day and being duly sworn acknowledged that the above fdrm was executed by him/her.
Witness my hand and notarial seal, this o/ rol day of N .C. .rcJ- , 20 a
\-jfi A 448///,, sa9A,A 1)2044'.
Notary
NT:Iry Public My commission expires /A^ /^02D AL/
wake County Fi
•?'
O/ AH CA VI° \\``\\
'

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:
NA NA NA
Name Phone: Office# Mobile#
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Deed Book No.NA Page No.NA Provide a copy of the most current deed.
Landowner 3 of Record:
NA NA NA
Name Phone: Office# Mobile#
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Deed Book No.NA Page No.NA Provide a copy of the most current deed.
Landowner 4 of Record:
NA NA NA
Name Phone: Office# Mobile#
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Deed Book No.NA Page No.NA Provide a copy of the most current deed.
Landowner 5 of Record:
NA NA NA
Name Phone: Office# Mobile#
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Page No.NA
Deed Book No.NA Provide a copy of the most current deed.

Continued from Item 1 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.
NA NA
Company 2 Name E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Phone: Office# NA Mobile# NA
NA NA
Company 3 Name E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Phone: Office# NA Mobile# NA
NA NA
Company 4 Name E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Phone: Office# NA Mobile# NA
NA NA
Company 5 Name E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Phone: Office# NA Mobile# NA