NCC221390_FRO Submitted_20220408

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 Virginia Line Solar
2. Location of land -disturbing activity: County Warren City or Township Warrenton
Highway/StreetDrewry-Virginia Line Road Latitude 36.52291 N Longitude-78.27919 W
3. Approximate date land -disturbing activity will commence: April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar Energy
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 367.5 ac
6. Amount of fee enclosed: $ 36,800 The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
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 Hugh Stephens E-mail Address hstephens(a-_)blueridgepower.com
Telephone [phone] Cell # N/A Fax # N/A
9
PIN:
2000852150,
2010150518
Landowner(s) of Record (attach accompanied page to list additional owners):
Kerr Lake Investments LLC 336-215-1599 N/A
Name
P.O. Box 2428
Current Mailing Address
Reidsville
NC 27323
Telephone
N/A
Current Street Address
N/A
City State Zip City
10. Deed Book No. 967 Page No. 603
Part B.
Fax Number
State
Zip
Provide a copy of the most current deed.
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.
Virginia Line Solar, LLC utility(a)pgrenewables.com
Name E-mail Address
130 Roberts Street 130 Roberts Street
Current Mailing Address Current Street Address
Asheville NC 28801 Asheville NC 28801
City State Zip City State Zip

CONTINUATION OF LANDOWNER(S) OF RECORD
Landowner(s) of Record (attach accompanied page to list additional owners):
PIN: Virginia Line Solar, LLC _ 828-348-7840 N/A
2001906694, Name Telephone Fax Number
2011108278
130 Roberts St. 7030 Drewry Virginia Line Rd.
Current Mailing Address Current Street Address
Asheville NC 28801 Manson NC 27553
City State Zip City State Zip
10. Deed Book No. 1094 Page No. 172 Provide a copy of the most current deed.

Telephone 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 State Zip
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
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.
1 to (�*
Type or rint name
Sign ture
Title or Authority
(2. 1-4 .'7621
Date
I, Cprir\" _,a Notary Public of the County of�wmb�
State of North Carolina, hereby certify that "t"Cn at, - 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 'L)t(avviVu 20 ZI
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