NCC221287_FRO Submitted_20220406

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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 NIA in the blank.)
Part A. Pitt Solar LLC -
1. Project Name PhaSc
2. Location of land -disturbing activity: County Pltt City or Township Bethel
Highway/Street Ford Road & Big Oak Road Latitude 35.799952 Longitude-77.351140
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar Power
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 30.1
6. Amount of fee enclosed: $ 5100 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Douglas Taylor E-mail Address Doug Ias.Taylor@sunenergyi .com
Telephone [phone] ext 104 Cell # 980447-4029 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Charles L Manning
Name Telephone Fax Number
7599 Main Street
Current Mailing Address
Bethel NC 27812
city
State Zip
Current Street Address
City
10. Deed Book No. 1802 Page No.- 511
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 companyorfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Pitt Solar, LLC
Name
9Q " Imo' acewaq Dskit
Current Mailing Address V
Moo; y r l+ i e N C
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
Current Ic
City
Fax Num

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:
CoLEPLy �,LoBAL INC
Name of Registered Agent E-mail Address
ion 5out�'i �rVorn 5�t. 1000
Current Mailing Address Current Street Address
0 kar[o-We- AIL d8A8)
City State Zip City State Zip
Telephone Fax Number
(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:
Lcwi7cr'f'
EngineeringFirm or other consultant
Pk4-ri c r4 Qcw 6trrK -Col 1
E-mail Address
_ ,,m K� S4-ri cr' 911 W aq 3 7 2
Individual contact person (type or print) 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
CEO__
Title or Authority
1 /26/2022
Date
I, kNk- ): JC CO'l (` —` l e l , a Notary Public of the County of C� 4 6u r
State of North Carolina, hereby certify that �Q AA L4 4%(, U 1 appeared personally
before me this day and being duly sworn acknowledged th t the above form was executed by him.
Witness my hand and notarial seal, this A\day of 20 c c�—
�N++MwM�
Notary
My commission expires
Nufto