NCC216697_FRO Submitted_20211207

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.
1. Project Name —Phobos Solar, LLC
2. Location of land -disturbing activity: County Nash City or Township_Middlesex
Highway/Street_ Frazier Road Latitude Longitude_
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ 884
6. Amount of fee enclosed: $ 57,460 . 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 Hallie Sheaffer_ E-mail Address [e-mail]_
Telephone_828.755.5011 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address
City
Current Street Address
State Zip City
State
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.
PhoboESolar,LLC _ [e-mail]
Name E-mail Address
_130 Roberts Road _Same__
Current Mailing Address Current Street Address
_Asheville_ _ NC 28801 Same
City State Zip City State Zip
Tel ephone^828.713.8875 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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number
State Zip
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.
f�>Cn Ca*
Type or
print name
Signature
CEO
Title or Authority
Date
I, CO-ir'unr\_Q_ UV )�tN ✓nCA1r1Y, , a Notary Public of the County of urwnn�-i�.
State of North Carolina, hereby certify that ��n ���' 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 V" day of )ur-k- , 20 21
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