NCC232920_FRO Submitted_20230928

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.)
P1.art Edgecombe Name Ed ecombe Solar
2. Location of land-disturbing activity: County EdgeCombe City or Township
Highway/Street ALT HWY 64 Latitude 35.932561 Longitude-77.676269
3. Approximate date land-disturbing activity will commence:October 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Solar
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 560 AC
6. Amount of fee enclosed: $36,400 . 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael Kaplan E-mail Address [e-mail]
Telephone [phone] Cell# Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners): See Attached
Penelo, LLC N/A N/A
Name Telephone Fax Number
1000 S Howard Circle N/A
Current Mailing Address Current Street Address
Tarboro, NC 27886 N/A
City State Zip City State Zip
10. Deed Book No. 1688 Page No.0711 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.
Invenergy Solar Development North America [e-mail]
Name E-mail Address
One South Wacker Drive, Suite 1800 N/A
Current Mailing Address Current Street Address
Chicago IL 60606 N/A
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
John Barefoot [e-mail]
Name E-mail Address
421 Fayetteville Street, Suite 600 N/A
Current Mailing Address Current Street Address
Raleigh NC 27601 N/A
City State Zip City State Zip
Telephone [phone] 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:
CT Corporation System N/A
Name of Registered Agent E-mail Address
160 Mine Lake Ct Suite 200 N/A
Current Mailing Address Current Street Address
Raleigh, NC 27615 N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
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.
Type or print name Title or Authority
S' nature Date
I, oelL NI err , a Notary Public of the County of
Lt,t1\10 iS
State of North Carolina, hereby certify that M,iC44P .. I1. 9LAr.) appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
444
Witness my hand and notarial seal, this l$ day of ,j t)L , 20 2 3
OFFICIAL SEAL
•1LT1 Notary
NOTARY NMI-STATE OF ILLINOIS
PAY COMMISSION EXPIRES:90/08/24 My commission expires 14053402.1

ADDITIONAL LANDOWNERS:
HC Bourne Family Cox Farm LLC
Name Telephone Fax Number
5021 Canopy Drive
Current Mailing Address Current Street Address
Marietta GA 30066
City State Zip City State Zip
Deed Book No. 1629 Page No. 0681 Provide a copy of the most current deed.