NCC241058_FRO Submitted_20240411

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.)
P1.art A.Project Name FCEMC - Hwy 53 to Shaw Hwy Transmission Line
2. Location of land-disturbing activity: County Pender City or Township Burgaw
Start:River Birch Rd and Hwy 53 Start 34.602492 End:34.620132 Start:-77.871228 End:-77.802546
Highway/Street Latitude _Longitude
End:Hwy 53 and Shaw Hwy June 2024
3. Approximate date land-disturbing activity will commence:
Electrical Transmission Line
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):6.84
6. Amount of fee enclosed: $ 700.00 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Gregg Cohn - Four County EMC E-mail Address [e-mail]
Telephone [phone] Cell# 910-789-7832 Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Four County Electric Membership Corporation 888-368-7289
Name Telephone Fax Number
1822 NC-53 W 1822 NC-53 W
Current Mailing Address Current Street Address
Burgaw, NC 28425 Burgaw, NC 28425
City State Zip City State Zip
10. Deed Book No. Page No. 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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Gregg Cohn - Four County EMC [e-mail]
Name E-mail Address
1822 NC-53 W 1822 NC-53 W
Current Mailing Address Current Street Address
Burgaw, NC 28425 Burgaw, NC 28425
City State Zip City State Zip
Telephone [phone] Fax Number 910-259-1817

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:
Don Gatton
Name of Registered Agent E-mail Address
PO Box 667 1822 NC-53 W
Current Mailing Address Current Street Address
Burgaw, NC 28425 Burgaw, NC 28425
City State Zip City State Zip
Telephone 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.
Gregg C VP of Engineering
Type or pr nt Title or
Authority
Sri
Signa944 Date
I, 5 Lit M . 2�V e4 b)r✓� , a Notary Public of the County of ?e-inCt.)2(-
State of North Carolina, hereby certify that req appeared
personally before me this day and being d sword acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this S day of ( elOV'( rU , 20 2.4i
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`fie, ' ��
�J NOTggy £ Notary
Seal
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Four County Electric
Membership Corporation A Touchstone EnergykCooperative 0.4(
1822 N.C. 53 West Telephone: [phone]
Post Office Box 667 Fax: [phone]
Burgaw, NC 28425 Web site: www.fourcty.org
February 5, 2024
Rhonda Hall
Division of Energy, Mineral, and Land Resources
Department of Environmental Quality
127 Cardinal Drive Ext.
Wilmington, NC 28405
Re: FCEMC — Hwy 53 to Shaw Hwy Transmission Line - Erosion Control Plan
Dear Rhonda:
Four County Electric Membership Corporation of North Carolina plans to replace an existing
transmission line per the submitted plans. Gregg Cohn of Four County EMC is authorized to be
the applicant and sign all applications related to this project.
If you have any questions or need additional information, please advise.
Very truly yours,
Don Gatton
Chief Executive Officer
Local Offices:
Burgaw 259-2361 • Elizabethtown 862-3551 • Rose Hill 289-4534

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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Name: FCEMC - HWY 53 to Shaw Hwy Transmission Line
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name below under which
you applied for funding through the Division of Water Infrastructure (DWI).
Is Project ARPA Funded ARPA Project Name ARPA Project#
No
2. Location of land-disturbing activity: County: Pender City or Township: Burgaw
Highway/Street: Various Latitude: 34.602492 Longitude:-77.871228
3. Approximate date land-disturbing activity will commence: 6/1/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Other: Utility Installation
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.84
6. 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).
7. Has an erosion and sediment control plan been filed? Yes-Will be Mailed or Hand-Delivered
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Gregg Cohn E-mail Address: [e-mail]
Phone: [phone] Mobile: [phone]
9. Landowner(s)of Record:
Landowner(s) of Record
Name Email Business Phone Mobile Phone
Four County Electric Membership Corporation 888-368-7289
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
1822 NC-53 W Burgaw NC 28425 1822 NC-53 W Burgaw NC 28425

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).
Primary Financially Responsible Party
Company Name Email Business Phone Mobile Phone
Gregg Cohn - Four County EMC [e-mail] 910-259-1852
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
1822 NC-53 W Burgaw NC 28425 1822 NC-53 W Burgaw NC 28425
Additional Financially Responsible Parties
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:
Registered Agent Information
Name Email Business Phone Mobile Phone
Don Gatton [e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
1822 NC-53 W Burgaw NC 28425 PO Box 667 Burgaw NC 28425
(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:
North Carolina Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
ECE Power [e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
115 Oakland Rock Hill SC 29730 115 Oakland Rock Hill SC 29730
Avenue Avenue

Additional Details
1. Stream Classification: B: Primary Contact Recreation, Fresh Water
2. Was Express Review Requested: No
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.