NCC232973_FRO Submitted_20231004

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.1. Project Name Newland to Banner Elk 69kV Transmission Line
2. Location of land-disturbing activity: CountyAVe1Y City or Township
Latitude 36.144645 Longitude-81 .898929
Highway/Street N/A
3. Approximate date land-disturbing activity will commence:September 1 , 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Electric Utility
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 12.8 acres
6. Amount of fee enclosed: $ 1 ,280 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 Steve Bishop E-mail Address [e-mail]
Telephone[phone] Cell# _ Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Mountain Electric Cooperative 423-727-1800 423-727-1822
Name Telephone Fax Number
604 South Church St. PO Box 180
Current Mailing Address Current Street Address
Mountain City TN 37683
City State Zip City State Zip
10. Deed Book No.Attached Page No.Attached 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.
Mountain Electric Cooperative
Name E-mail Address
1373 Elk Park Hwy PO Box 1240
Current Mailing Address Current Street Address
Newland NC 28657
City State Zip City State Zip
Telephone [phone] Fax Number 828-733-3213

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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,J� give name and street address of the Registered Agent: /
Kyle, /T OI/SGfQW kAo/T.5-4-4 ✓7Moun,4ih 8/CL�i' ,40►+1
Na(ne of Registered Agent E-mail
mail Address
I
,Q. go , /2/0 /373 £/4 Prk ,'//
N/
Current Mailing Address Current Street Address
New le4I /Ve 2t657 /(4)1ann N�
City State Zip City State Zip
Telephone J2 8 7 3 7 e3 0 7 Fax Number gL 8 7 33 3 2 i3
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 informationffo Jshould there be any change in the information// provided herein. A'
k, le No //s&1q`✓ IPwn4. b /G Co-7 �)/Sri! /�fR"l�r
Ty� or print name Title or Authority
a'M 9 /9 - 23
S' ature Date
I, VV 14 IT/ 4 PA J Ai . SKI JQ,, , a Notary Public of the County of AVeIV A
1 . -1
State of North Carolina, hereby certify that _\( C \(0,II-5r a IA) appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
ICI
Witness my hand and notarial seal, this l fhday of Se -te,f-hhL , 20 2S
,. WHITNEY M STYLES I / t p� ` (J/� G-iim__)
,�etn0� NotaryPublic, North Carolina�' Vl/t, /1` /i Ali l
ky ;fit Avery county Notary
Sea °' My Commission Expires
--� November 13,2027 C v ' 18-1_ ' �0n -
"""""'My commission expires Iv ►'l L