NCC230724_FRO Submitted_20230317

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 N/A in the blank.)
Part A. Parkwood Substation
1. Project Name
2. Location of land -disturbing activity: County Union City or Township Monroe
Highway/Street 5915 Lancaster Hwy Latitude N34 ° 53' 17" Longitude W80 ° 38' 04"
3. Approximate date land -disturbing activity will commence: February 15, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.0
6. Amount of fee enclosed: $ 800 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Matt Baucom E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Union Electric Membership Corporation
704.289.3145
Name
Telephone Fax Number
1525 N Rocky River Rd
Current Mailing Address
Current Street Address
Monroe NC 28110
City State Zip
City State Zip
10. Deed Book No. 7895 Page No. 468 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.
Union Electric Membership Corporation
greg.andress(Ld)union-power.com
Name
E-mail Address
1525 N Rocky River Rd.
Current Mailing Address
Current Street Address
Monroe NC 28110
City State Zip
City State Zip
Telephone [phone]
Fax Number

2 (4 1 f the F ram i d l y Fqo ra ti e Pary i s ro t a re3 cb t d it rh Qrb re g ke ra a a-d strEd atte s
o f the d3§ g-dai M rh Qrb ra Fgrt:
t"
Gret M I i rg de s
sty ;fie ap
Te I Oue
Ergl MES
CLrret are# Mes - — - -
City :fie
Fax Nrhe
ap
(I j If the Fj nae i dly Flo ra ti a Fury is a Fh tff§i p a o the prsm eig rg i n Lb re s udy ai
am -ad m-p Akh a aW d tte Orti Hate d lured Ida If the Fi ra-dily F� a li e
F y is a (b rpo rho n , g\e nm aid stred a&Es d the Rjsteai )*t:
Gregory S Andres: greg.andress@union-power.c
We o f F?4 stead Apt Erg I MEs
1525 N Rocky River Ri
Cret M I i rg MEs &ret SreA motes
Monroe, NC 2811
sty Me
-rdoue LO4.289.314
ap Cty
Fac Nrhff
;fie ap
-he Am i rfadi rn is he a-d amrat to tf a b8d d T kulu* a-d b4i Ef a-d \a; proi dad
bj ra u-ctr cEth (Ti s fan rrg be s gel 4( the Fi rari d I y Fdgxrs b e Pffgn if ai i rd u did
a h s dtrgi n-fat , ar i f nd m i rd u d.d , by an cfif(ff, d reda , pate, ar ra, jsteed ayt Wh
the aft ty to ea; ate i rstru-ats fa ft Ft na-o d I y Firs b e Pass I g(e to pro dr
axra Ed i rfaeti rn sl W d thre be ay daV i n th=_ i rfagi cn pro chd hre n
Smote
----------------------------------
Ttl e or A i ty
iu J5 JoaD
de
1, f" P 1 5 cN-,PS C-\ , a may Rb i s d tb tarty d -�
Me d firth QoYna, hammy that � e--q S ftf6rah
pesmdly bare re the cbr ad barg IbA MbAtjd thd tb dne fan was
exec Lted by h m
1 had aid rrtaal ssd the 'dtDd . ay of COS �QPT
OW
WWY I ch am�
ab [ r 15, II My o7n� E qO
Wires re