NCC231719_FRO Submitted_20230629

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 Longleaf Pine Solar,LLC
Davie Advance
2 Location of land-disturbing activity: County City or Township
1415 Beauchamp Road 35.979675 -80 458
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
2/1/2023
3 Approximate date land-disturbing activity will commence.
Commercial Solar
4 Purpose of development(residential, commercial, industrial, institutional, etc.)
40.97
5 Total acreage disturbed or uncovered (including off-site borrow and waste areas)
6 Amount of fee enclosed: $$4,100.00 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 ❑x No ❑
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name E-mail Address
Phone: Office# Mobile#
9 Landowner(s) of Record (attach accompanied page to list additional owners)
Blackwelder Investment Properties
Name Phone: Office# Mobile#
433 Baltimore Road
Current Mailing Address Current Street Address
Advance,NC 27006
City State Zip City State Zip
670 891
10. Deed Book No. Page No 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)
Longleaf Pine Solar,LLC
[e-mail]
Company Name E-mail Address
700 17th Street,Suite 700
Current Mailing Address Current Street Address
Denver,CO 80202
City State Zip City State Zip
720-400-8434
Phone: Office# Mobile#
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:
Northwest Registered Agent Services, Inc. [e-mail]
Name of Registered Agent E-mail Address
4030 Wake Forest Road, STE 349
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Phone: Office# Mobile#
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:
Northwest Registered Agent Services, Inc. [e-mail]
Name of Registered Agent E-mail Address
4030 Wake Forest Road, STE 349
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Phone: Office# Mobile#
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.
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.
Brandon Conard Manager of Financially Resposnsible Person
Type or print name Title or Authority
--------` 12/20/22
Signature Date
I, 41-e—pkt.n ill actor•L7 , a Notary Public of the County of D CAvt-r
Goloro..ap
State of r 4 i-her of a, hereby certify that BcK r O rs 60h u.ra appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her
Witness my hand and notarial seal, this Z t day of 04 Cc on b1-r 20 1 Z.
No y
Seal
My commission expires 07 /09 /2 o2.b
1. STEPHEN MALONEY
Notary Public
State of Colorado
Notary ID#20224026729
My Commission Expires 07-08-2026

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City ,State Zip
Deed Book No Page No. Provide a copy of the most current deed.
Landowner 3 of Record
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No Page No. Provide a copy of the most current deed
Landowner 4 of Record.
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed
Landowner 5 of Record.
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No Page No_ Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#