NCC223494_FRO Submitted_20221010

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project NameHampstead Point of ,.,Delivery Station
2. Location of land -disturbing activity: CountyPender City or Township Rocky Point
Island Creek Road 34.371867-77.781931
Highway/Street Latitude{decimal degrees} Lori gltUde(decimal degrees)
I Approximate date land -disturbing activity will commence:'Jan-2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):8.4
6. Amount of fee enclosed: $900 . 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).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Gregg A. Cohn (Four County EMC) E-mail Address [e-mail]
Phone: Office # 910-259-1821 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Four County Electric Membership Corporation 910-259-1821
Name Phone: Office # Mobile #
1822 NC 53 West 1822 NC 53 West
Current Mailing Address Current Street Address
Burgaw, NC 28425 Burgaw, NC 28425
City State Zip CityGG State Zip
10. Deed Book No.4771 Page No. 6?9 V81 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Four County Electric Membership Corporation [e-mail]
Company Name
1822 NC 53 West
Current Mailing Address
Burgaw, NC 28425
E-mail Address
1822 NC 53 West
Current Street Address
Burgaw, NC 28425
City State Zip City State Zip
Phone: Office # 910-259-1821 Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Don Gatton
Name of Registered Agent
1822 NC Highway 53 W
Current Mailing Address
Burgaw NC 28425
City
State Zip
[e-mail]
E-mail Address
1822 NC Hiahwav 53 W
Current Street Address
Burgaw NC 28425
City State Zip
Phone: Office # 91 0-259-2361 Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name,give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best ofmyknowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney -in -fact, Vrifnot on individual, by an officer, director, partner, Or registered agent with
the authority to execute instruments for the Financially Responsible F`mdm). | agree to provide
corrected information should there be any change in the information provided herein.
VP f Engineering
Typ eor Title orAuthority
Signat(fee-"" Date
�� �
[ aNu��Pu��ofU�{oun��K� =^^ ="��������
�� � Cohn State ofNo�h(�oro|ina.hereby oer�fvthad~�"n�� appeared personally
before me this day and being duly sworn acknowledged that the aboveform was executed by him/her.
VVdneeo my hand and notarial seal, this /�f4— ayof S 42 �et-yl 2
My commission expires

6/28/22, 7:58 AM
North Carolina Secretary of State Search Results
• Upload a PDF Filing • Order a Document Online • Add Entity to My Email Notification List • View Filings
Electric Membership Cooperative
Legal. Name
Four County Electric Membership Corporation
Information
Sosld: 0054961
Status: Current -Active Q
Date Formed: 12/3/1937
Citizenship: Domestic
Fiscal Month: December
Annual. Report Due Date:
Registered Agent: Gatton, Don
Addresses
Reg Office
1822 NC Highway 53 W
Burgaw, NC 28425
Burgaw, NC 28425
https://www.sosnc.gov/online—services/search/Business—Registration_Results 1/1