NCC223596_FRO Submitted_20221020

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 N/A in the blank.)
Part A.
1. Project Name Carolina Poultry Power Rg3, LLC - CHP Plant
2. Location of land -disturbing activity: County Lenoir City or Township Moseley Hall
Highway/Street NCSR 1514 - Brothers Rd. Latitude(dadmal degrees) 35.315187 Longitude(dedmei degrees)-77.780524
3. Approximate date land -disturbing activity will commence: September 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.4 ac
6. Amount of fee enclosed: $1,100.00 . 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 ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Richard Deming E-mail Address rich @eastenergylIc.corn
Phone: Office # 252-253-3300 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of LaGrange 252-566-3186
10
Name
203 S. Center Street
Current Mailing Address
Phone: Office #
203 S. Center Street
Current Street Address
LaGrange_ NC
City State Zip City
Deed Book No. 1037 Page No. 912
LaGrange NC 28551
State
Mobile #
28551
Zip
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 names) of the owner(s) may be listed as the financially responsible party(ies).
Carolina Poultry Power Rg3, LLC
Company Name
3730 North Main Street
Current Mailing Address
Farmville NC 27828
City State
Phone: Office # 252-253-3300
[e-mail]
E-mail Address
3730 North Main Street
Current Street Address
Farmville NC 27828
Zip City
Mobile #
State
Zip
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:
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)
(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 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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Richard Deming
Type or print name
Signature
Manager
Title or Authority
Date
-------
I, U-26LjL ? � Ph G �I�[ , a Notary Public of the County of `
State of North Carolina, hereby certify that O-Ld appeared personally
before me this day and being duly sworn acknowledged that the ab orm was executed by him/her.
Witness my hand and notarial seal, this _L-day of , 20 i -
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
Company 3 Name
Current Mailing Address
Company 4 Name
Current Street Address
City State Zip City
Phone: Office # Mobile #
E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address
State Zip
State Zip
State Zip
State Zip