NCC223311_FRO Submitted_20220922

NC Department of
Environmental Quality
'-PAv ID —Zo Zz _p 2y Received
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT Winston- S ilem
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 Davidson County Solar Site
2. Location of land -disturbing activity: County Davidson City or Township Lexington
Highway/Street New Jersey Church Rd Latitude 35.749306 Longitude-80.289582
3. Approximate date land -disturbing activity will commence: November 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Stabilization
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 34.8
6. Amount of fee enclosed: $ 2,275 . 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 Joshua Allen, PE, CFM 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):
Longroad Land Holdings II, LLC
Name Telephone Fax Number
330 Congress Street, 6th Floor 330 Congress Street, 6th Floor
Current Mailing Address Current Street Address
Boston MA 02210 Boston MA 02210
City State Zip City State Zip
10. Deed Book No. 02407 Page No. 0546 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.
Longroad Land Holdings II, LLC [e-mail]
Name E-mail Address
330 Congress Street, 6th Floor 330 Congress Street, 6th Floor
Current Mailing Address Current Street Address
Boston MA 02210 Boston MA 02210
City State Zip City State Zip

(�T' . , !t'� . .+I.Yliri'.r'�f..:f,� Yr; s_r,: !. :;O. . _ .::1 - (, .�((G :17 t%fJi(il,.?Fi y)i1115! ..:a(} .�.Y+::; i(;1 . ,.I'a!i!,,: i'l' .'r , ..I:d1a C:•`t+
''i !3,=' ;ir;f •,<j � ;J`,ri'1`s(ti t�._ t) ' : :al. ,...,. � � ! z! n � ..� 7 ,;',.•,:' , _ , ,Y,r.l ilLY`i Y`.t! )�i.i ,(!..- t_'" (il'i.,.�f'i: , �}:.. ..•llla ,::•L.(f� �7,�1Pi..
(>tG3!:Ci^•'1 icy" -::'ti ni it .1 . , 1 �51 �1 ;iPi,:.i„ �i°;l.f" 6 1� ,.r,( r;iitG''! } �U `r?i�ii Y�'t>. +f.E ..i i'` ,'4c :. '•/�t! �; i.,.
tr%' .� , liras r r •.', 'CI +c'jl'a 4'! �:)E3iC71`i , f
.'oC - ,) .i(.ti. •.'y` `,'�i f i.1"c;U. t)l7;:i. _
�Ot.�'Ha ,,. .iilF,C.�h' .. .•�i r.1 '.ilrta.. �1 •..f..;, K., .i. '
-.. ,. - -- I -- _..... ...._.__._. ._,i � . _._.�._ .� _i-.rr: )('Z„ ?'S;lf}; !+p°r,; ;/,f'•'!i:;f> ri.7 i.�h1f3,,.. _':if�( (;�n i. '.'-3 I{1i,CC_: �r'� .
r ,�i��J;i .I .s�ii�l.:.'1'ii .'4..f., •1{?�. .J ,.' 7F;!: _s-{) „'!i;lf"(nt-,/;. ••,, .. ., f
_.... ... __._. ... ".F ,r ..,... 1.. L .',; L�!JttC)s` 'r. I,r..[fJr' € 1.,,: ,,,.J;�fY! Iti`j;?e3CitlJ 'rt! '�1: (•c� ,;±
1:�s'-�t iJOl� 'n ?!; r,..,1 .)f}.<.�r'i �t::+1 trtsi,F•,. tir_1C,+ i„ .__.._. .._...._... _ ._ _ 1 5-��;.. .. ,-�� 1. ' t.)t Tin, �:7
.I
J` 1i'.;':; i.i ("!. i �i(+2 r�.. •. c.,f � '��, ; i' {fl EYi �!!>._,. ,�-;i(€!t, l?-, . ,Ce (1C,1!�:f)`�;3 , ,i .., i'-1 .�
� JV!t'il.3 �1(11(�11J, ,.:!Li•r. s�, pJown AMawn: Man
"tiil`�.r?'>Y'e:"I;,Jlti!;.. , �, c r• f. �t i) ,::1�! ,f,i;lr'Y n�!I;. i. ::(i56t�:
MY
,
i .),i_f ,:t :�i:i�ilGat k.:�:-.t ,:'C;•:.Jr�.: I
'� 1'4Y�• � t iil'� , ,'(s ., �-L.?. r:_ � -,r ,�ft:�e Jil i.� � i[:., t!- }r. :I`_�... �.
r

Telephone [phone] Fax Number [phone]
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 - ail Address
(,o: k �'-ni--t
Current Mailing Address
Current Street Address
4f � kyr� m�- `1.� I Q It
City State Zip City State Zip
Telephone '�t'Z - L-)A -• i. � Sk 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 State
Telephone
E-mail Address
Current Street Address
Zip City
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.
Michael U. Alvarez
Type or print ame
�,C
Signature
Chief Operating Officer
Title or Authority
October 22, 2021
Date
a Notary Public of the County of
State of North Caro ' . hereby certify that
personally before me th ay and being duly sworn ackn
by him.
appeared
ed that the above form was executed
Witness my hand and notarial seal`t4 ____Zd6ay of 20
Sl=E Dr'CTF}�1 �D
Seal
N
My com
expires

ofr sr. i r d!:ov", 10 EPA as,
g 00, tic.- "V�; i
ismu I yWR'(Vi,v:f
i� i:!;"{
:!I -OP4 awnwrA
0 lo
I y"A downywi wh to vamp-, il:tO 1,3111WI Wip
...
. ... .... ... .. .....
%Fg MA Leal :l
.......
JpA qmr,
0 1) CA 1 0 A 110
w b�fr�n191
, J'
�;rYwjc
A :­f'ikbeso22w
w"Nowl nu 1 noal.'Il A! yd hwpw wi irmi it( t old ff iubw Isom Wn
Mps Me"s Unleowl
lbolwy QW n yamn nslo
Vomit 's 1 w (: 0) jouNd y.niums WHO
ON -An of spl.;
""llai-ofumv
nu Of swnfmc- 0 n wX9 ct y"Umus eY
DOE mq�"Nllolw 90A w"AM5
Ynk A
Wsh -qk"
tat
- - --------
uo� Ina vn�
v! 00 �s my A Z j".4 QVit n
its) g yjah ow own -1 40wriq

CrE RMFI CATE OF ACKH1 0MWLr IP)WHI ENT
A notary public or other officer completing this certificate verifies only the identity
of the individual who signed the document to which this certificate is attached,
and not the truthfulness, accuracy, or validity of that document.
State of California
County of -MNJ 92A-JGcSco
On OC[ceet2 26 ; 2O?-1 before me, r-Do , 1' 5f AV-ti V U1&Q C_ ,
(Here Insert name ancl title Or t icer
personally appeared W CktAS L \. A hLVA'IR---Z
who proved to me on the basis of satisfactory evidence to be the person�Kwhose
ame ;�e subscribed to the within instrument and acknowledged to me that
he e/Ky executed the same ingMer/tk& authorized capacity(jeg), and that by
1 hgrr/tl & signature(sl on the instrument the person(SI, or the entity upon behalf of
which the personxacted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph is true and correct. _
•• . JOCELY KN OO
WIT S my hand and official seal. -Commission LI 2302816
Z:=<.
z � . � NOTARY PUBLIC-CALIFORNIA
ALAMEDA COUNTY
My Comm. Expires: SEPTEMBER 19, 2023
Public/Signature (Notary Public Seal)
® INSTRUCTIONS FOR COMPLETING THIS FORM
ONAL OPTIONAL INFORMATION Thisf,,,,,,plieswith currentColiforniastatutesregarding)?otasysvordinganrl,
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages
CAPACITY CLAIMED BY THE SIGNER
❑ Individual (s)
❑ Corporate Officer
(Title)
❑ Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
if needed, should be completed and attached to the document. Acknowledgments
T •om other states may be completed for documents being sent to that state so long
as the wording does not require the California notary to violate California notary
law.
• State and County information must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
• Date of notarization must be the date that the signer(s) personally appeared which
must also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or her
commission followed by a comma and then your title (notary public).
• Print the name(s) of document signer(s) who personally appear at the time of
notarization.
• Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
he/she/they- is /are ) or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
• The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges, re -seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
• Signature of the notary public must match the signature on file with the office of
the county clerk.
Additional information is not required but could help to ensure this
acknowledgment is not misused or attached to a different document.
Indicate title or type of attached document, number of pages and date.
Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i.e. CEO, CFO, Secretary).
2fs 3 r version v-v vv" it colmryGl<:sses.com 8fs14�73-98E 3 • Securely attach this document to the signed document with a staple.

rx??IWHOM
Alo.9o"Jd..;).:;!;Git''F YAlrF;)w