HomeMy WebLinkAboutNCC217186_FRO Submitted_20220111FINANCIAL RESPONSIBILITYIOWNERSHIP 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.
Project Name Beckwith Solar
2. Location of land -disturbing activity: County Columbus I City or Township Tabor
Highway/Street Carolina Road Latitude 340 9'17.90"N Longitude 78°53'25.34"W
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 36.70 Acres
6. Amount of fee enclosed: $ 2,405 . 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 X Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Amber Penland
Telephone 828-707-6056 Cell #
E-mail Address amber@u-renew.com
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
PAMELA C JSPIVEY 1 `13-1-15,'� - 3 L-17,'�
Name Telephone
103 CAROLINA RD
Current Mailing Address
103 CAROLINA RD
Current Street Address
Fax Number
Tabor City
NC
28463
Tabor City
NC 28463
City
State
Zip
City
State Zip
10. Deed Book No.
416
Page No.
541
Provide a copy of the most current deed.
Part B.
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.
United Renewable Energy LLC
Name
5895 Shiloh Rd Ste 104
Current Mailing Address
_ 0-ul-renew com
E-mail Address
5895 Shiloh Rd Ste 104
Current Street Address
Alpharetta GA 30005 Alpharetta GA 30005
City State Zip City State Zip
Telephone 770-235-7829 Fax Number 888-649-0610
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:
Keith Herbs keith(5u-renew.com
Name E-mail Address
1880 Adare Dr
Current Mailing Address Current Street Address
Clemmons NC: 27012
City State Zip City State Zip
Telephone 704-807-4723 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:
Name of Registered Agent
Current Mailing Address
City
E-mail Address
Current Street Address
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.
Amber Penland
Type or pri t name
Signature
Director of nneratinns
Title or Authority
Date
a Notary Public of the County of
State of North Carolina, hereby certify that A4,48_1 Pam„ 10-A j 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 /VO%jg" , -49-" , 20 2- s
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