NCC215872_FRO Submitted_20211109

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. Oak Solar - Phase B
1. Project Name
2. Location of land -disturbing activity: CountyNorthampton City or Township N/A
Highway/Street NC HWY 46 Latitude 36°31'36.5"N Longitude 77046'40.3"W
3. Approximate date land -disturbing activity will commence: 05/01 /21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar Facility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):. 814 ac
6. Amount of fee enclosed: $ 52,910 . 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 Nicholas Tillson E-mail Address [e-mail]
Telephone [phone] cell # N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Lewis Belmont Properties, LLC 252-534-6001
Name Telephone Fax Number
PO Box 768
Current Mailing Address Current Street Address
Jackson NC 27845
City State Zip City
10. Deed Book No. 100+ Page No. 512
State
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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Oak Solar, LLC [e-mail]
Name E-mail Address
192 Raceway Drive
Current Mailing Address
192 Raceway Drive
Current Street Address
Mooresville NC 28117 Mooresville
City
State Zip City
Telephone [phone] Fax Number N/A
NC 28117
State Zip

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:
N/A
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 Registerej Agent:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
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.
Kenny Habul
Type or print name
Signature
Manager
Title or Authority
Date
I, ,t�U✓�� t �.'�C a Notary Public of the County of
State of North Carolina, hereby certify that /Levi vi � 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 day of �'%vy�� 20 2
PZ N E Y Al
J r Ission bC r�S ,
• oTAA4�^��c ; Notary
Seal _ �, p
'OUsi:2 My commission expires /eZlq 1.2022—
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