NCC215965_FRO Submitted_20211027

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION88V120U7
Noperson may initiate any land -disturbing activity on one or more acres as covered bythe Act before
this form and anacceptable erosion and sedimentation uonbn| plan have been completed and approved
by the Land {3ua|dx 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 NIA inthe b|ank.)
Part A.
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1. Pn�ootNann Partin Solar
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2' Locatk>nof�nd-d)abud�nQaoUv�v:Coun ^^U�y �vorl�nwnahiElkin
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Highway/Street Longitude ~~
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3. Approximate date land -disturbing activity U vityv�oonnn�enue:^ ASAP
4. Purpose ofdevelopment (neoidende].commercial, industrial, institutional, etc.). ����V
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8. Amount of fee enclosed: ^-' The Express Permitting application fee is o dual charge.
The normal fee of$85.00 per acre is assessed without m ceiling amount. In addition, the Express
Permitting supplement is� $250.00 per ocna up to eight acrem, after which the Erpnaea Permitting
supplemental fee is a fixed $2.000.00 (Example: 9 nonee total is $2.585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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7. Has mnerosion and sediment control plan been �|ed? Yes No Enu\osn ^^
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Nam Steve [aV'Or E-mail Address GtGVlOr@depCo0OoVe['COD
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Telephone ~�~ ~~' ~'�~ {�eU#'`''^ Fox# '~^^
9. Landowner(s) of Record (attach accompanied page to list additional owners):
TaV|Oe Amy Et Al
Name Telephone Fax Number
105 V8llBVbn3Ok Drive; PO BOX625
Current Mailing Address
Elkin, NC 28621
City
Current Street Address
State Zip city
Zip
1A��
10. Deed Book No. '~~' Page No. 614
Provide acopy ofthe most current deed.
Part B.
1. Company( or firm(s) 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 proplietorship,
the name of the owner or manager may be listed as the financially responsible party.
DEPCOM Power Inc.
Name
9185 E Pima Center Pkmv#1AO
Current Mailing Address
E-mail Address
Current Street Address
Scottsdale AZ 85258 Scottsdale AZ 85258
City
State Zip City
91
�RO-���O_��1O
|e|*Pkon '-- —' - --'- Fax Number.

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:
Timmons Group (Derrick Johnson, PE) [e-mail]
Name
E-mail Address
5410 Trinity Road, Suite 102
5410 Trinity Road, Suite 102
Current Mailing Address
Current Street Address
Raleigh, NC 27607
Raleigh, NC 27607
City State Zip
City State Zip
Telephone [phone]
Fax Number [phone]
(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:
Corporation Service Company
N/A
Name of Registered Agent
E-mail Address
2626 Glenwood Avenue, Suite 550
2626 Glenwood Avenue, Suite 550
Current Mailing Address
Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City
State
Telephone [phone]
Zip City State Zip
Fax Number N/A
(c) In 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:
Timmons Group
Engineering Firm or other consultant
Jacob Dooley, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
919-866-4937 N/A
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.
Type or print name
Signature _
P
s z-N I O/Z l'i L C �jZ�S/ice
Title or Authority
9123 jZ/
Date
HIJSTe a Notary Public of the County of
State of North Carolina, hereby certify that C-1 EA04C MWO- , 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 _L3 day of S��i�, 20'2A
ROBYN HEISTER Notary
Notary Public -State of Arizona
MARICOPA COUNTY
# 582058 M commission expires © 3IM 15 � ZOZ1�
Commission * 5, 202 y p
Expires March 15, 2024