NCC223450_FRO Submitted_20221025

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 NIA in the blank.)
Part A. Necal Solar Electric Power Plant
1. Project Name
2. Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street 4945 N NC HWY 49 Latitude 36.18994 Longitude-79.29648
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 29.2
5. Amount of fee enclosed: $ 1950.00 . 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 x Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Clay Holiday E-mail Address cholidayCa)stratacleanenergy.com
Telephone [phone] x733 Cell # 910-527-5119 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Teena Burton
Name Telephone Fax Number
113 Legacy Lane, 113 Legacy Lane,
Current Mailing Address Current Street Address
Durham NC 27713 Durham NC 27713
City State Zip City State Zip
10, Deed Book No. 3879 Page No. 0418 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 f►mr is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Strata Solar Development, LLC [e-mail]
Name E-mail Address
800 Taylor Street, Suite 200 800 Taylor Street, Suite 200
Current Mailing Address Current Street Address
Durham NC 27701 Durham NC 2770
City State Zip City State Zip
Telephone [phone] Fax Number919-724-4146

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
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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 ll esponsible Person). i agree to provide
corrected information should there be any change in the hformation provided herein.
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'AA � Date
a Notary Public of the County of t_ . )c kJL,C_
State of North Carolina, hereby certify that SA0.'4W5 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 S
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Seal
day of r , 20 2,1
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