NCC230332_FRO Submitted_20230208

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 Solarls
2. Location of land -disturbing activity: County Caswell City or Township Stoney Creek
Hi hwa /street Oakus Page Road 36.297131-79.454710
9 Y Latltude(decimal degrees) LongltUde(decima� degrees)
3. Approximate date land -disturbing activity will commence: Upon Permitting
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar Farm
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 35.0 acres
6. Amount of fee enclosed: $ 3,500.00 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 Zx No ❑x
a
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name GEORGE DORGU E-mail Address [e-mail]
Phone: Office # 336-686-7388 Mobile # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
GEORGE DORGU 336-686-7388 n/a
Name
7892 ELIZABETH DRIVE
Current Mailing Address
OAK RIDGE, NC 27310
City
10. Deed Book No. 642
Phone: Office # Mobile #
7892 ELIZABETH DRIVE
Current Street Address
OAK RIDGE, NC 27310
State Zip City
Page No. 79
State
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 name(s) of the owner(s) may be listed as the financially responsible party(ies).
Solaris Solar Inc
Company Name
114 National Highway
Current Mailing Address
Thomasville, NC 27360
City State Zip
Phone: Office # 336-285-1005
[e-mail]
E-mail Address
114 National Highway
Current Street Address
Thomasville, NC 27360
City State Zip
Mobile # n/a
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:
George Dorgu
Name of Registered Agent
7892 ELIZABETH DRIVE
Current Mailing Address
OAK RIDGE, NC 27310
City State Zip
[e-mail]
E-mail Address
7892 ELIZABETH DRIVE
Current Street Address
OAK RIDGE, NC 27310
City State Zip
Phone: Office # 336-686-7388 Mobile # n/a
George Dorgu
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:
n/a n/a
Name of Registered Agent E-mail Address
n/a n/a
Current Mailing Address Current Street Address
n/a n/a
City State Zip City State Zip
Phone: Office # n/a Mobile # n/a
n/a
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.
n/a
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.
T 1
TVDe or p int me
Signat re
D1�4);'l e
Title or Authority
Date
I, C YY1G \G,LP� a Notary Public of the County of �Ciyron(Q
State of North Carolina, hereby certify that( 1)ICU* ((2) appeared personally
before me this day and being duly sworn acknowl ged that Me above form was executed by him/her.
Witness my hand and notarial seal, this _day of 20 ZZ
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