NCC223783_FRO Submitted_20221129

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Brunswick Electric Membership Corporation - Mt. Pisgah Rd. Driveway
2. Location of land -disturbing activity: County Brunswick City or Township Lockwood Folly
Highway/Street Mt. Pisgah Road Latitude 34.005322 Longitude-78.301311
3. Approximate date land -disturbing activity will commence: September 1, 2019
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial - Driveway
5.
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.9 Acres
6. Amount of fee enclosed: $ 945.00 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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:
NameJustin Pruitt E-mail Address [e-mail]
Telephone [phone] Cell # 910-540-8204 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Brunswick Electric Membership Corporation 910-754-4391
Name Telephone Fax Number
P.O. Box 826 795 Ocean Highway West
Current Mailing Address Current Street Address
Shallotte NC 28459 Supply NC 28462
City State Zip City State Zip
10. Deed Book No. 04040 Page No. 0892 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.
Brunswick Electric Membership Corporation [e-mail]
Name E-mail Address
P.O. Box 826 795 Ocean Highway West
Current Mailing Address Current Street Address
Shallotte NC 28459 Supply NC 28462
City State Zip City State Zip
Telephone [phone] 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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
(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:
Joshua L. Winslow
Name of Registered Agent
P.O. Box 826
Current Mailing Address
Shallotte NC 28459
City State
Telephone [phone]
Zip
[e-mail]
E-mail Address
795 Ocean Highway West
Current Street Address
Supply NC 28462
City State Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Summit Design Group [e-mail]
Engineering Firm or other consultant
Rose McPherson
E-mail Address
910-840-1444
Individual contact person (type or print) Telephone 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.
Joshua L. Winslow
Type or na
CEO / General Manager
Title or Authority
Date
�2 . !'t 1 A a Notary Public of the County of rt�4tkSl()r �C
State of North Carolina, hereby certify that -t C)S kUA �. (� i �� 0 (,J appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
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Witness my hand and notarial seal, this -(`day of 20AL
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Q- Y 'jNotar 2 5eal P P, ' �p ® Z= My commission expires
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