NCC223647_FRO Submitted_20221031

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. South Denver Substation
1. Project Name
2. Location of land -disturbing activity: County Lincoln City or Township Catawba Springs
Highway/Street N Little Egypt Road Latitude 35.473781 Longitude -81.023022
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.)._Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.1 acres
6. Amount of fee enclosed: $ 325.00 . 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Judson Wortman E-mail [e-mail]
Telephone [phone] ext.416 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
L.S.M.J.
Name Telephone Fax Number
438 S. Highway 16
Current Mailing Address Current Street Address
Stanley NC 28614
City State Zip City State Zip
10. Deed Book No. 2363 Page No. 668 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.
Rutherford Electric Membership Corporation (REMC) [e-mail]
Name
PO Box 400
Current Mailing Address
Morganton NC 28680
City State Zip
Telephone [phone] ext.416
E-mail Address
614 Carbon City Road
Current Street Address
Morganton NC 28655
City State Zip
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:
Elizabeth T. Miller [e-mail]
Name of Registered Agent
PO Box 800
Current Mailing Address
Rutherfordton NC 28319
City State Zip
Telephone [phone]
E-mail Address
346 North Main Street
Current Street Address
Rutherfordton NC 28319
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 Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Colon L. Saunders
T Rei or print name
Signature
V.P. of Operations
Title or Authority
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Date
I, AdA", W. `XCAO, , a Notary Public of the County of PArfard
State of North Carolina, hereby certify that Cola» Z. .S4LIAdGfs appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness r, Xy% igmoj�nd notarial seal,
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