NCC233056_FRO Submitted_20231013

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR E D E L L No person may initiate any land-disturbing activity on one or more acres, '/2 acre or more inside a
c o u N T v N C watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning& Development, Erosion Control Section.
(Please type or print)
Part A.
1. Project Name Energy United - Statesville
2. Location of land-disturbing activity: County Iredell City or Township Statesville
Highway/Street Mocksville Latitude 35.808744 Longitude -80.811040
3. Approximate date land-disturbing activity will commence: 8/14/2023
4. Purpose of development(residential, commercial, industrial, institutional,etc.): industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.15
6. Amount of fee enclosed: $ 1,400 . An application fee of$175.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed,a flat fee of$100.00 is assessed.
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 Steven J. McCachern E-mail Address [e-mail]
Telephone [phone] Cell# 704-929-0180 Fax# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Energy United Electric Membership Corp 800-522-3793
Name Telephone Fax Number
PO BOX 1831 567 Mocksville Highway
Current Mailing Address Current Street Address
Statesville NC 28687 Statesville NC 28625
City State Zip City State Zip
10. Deed Book No. 63 Page No. 144 Provide a copy of the most current deed.
874 369
2329 612
Part B. 805 123
490 539
490 542
1. Person(s)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive list of all
responsible parties on an attached sheet):
Energy United Electric Membership Corp [e-mail]
Name E-mail Address
PO BOX 1831 567 Mocksville Highway
Current Mailing Address Current Street Address
Statesville NC 28687 Statesville NC 28625
City State Zip City State Zip
Telephone Fax Number
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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, give name and street
address of the Registered Agent:
Thomas Golden [e-mail]
Name of Registered Agent E-mail Address
PO Box 1831 567 Mocksville Hwy.
Current Mailing Address Current Street Address
Statesville NC 28687-1831 Statesville NC 28625-8269
City State Zip City State Zip
Telephone [phone] Fax Number
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 by any change in the information provided herein.
Steven J. McCachern Vice President Energy Delivery
Type or print name �f Title or Authority
Signatures Date
I,V `t e h . �r\S-k-i olrl ,a Notary Public of the County of 1—OC S _
State of North Carolina, hereby certify that S-teYer, J. iNA c.Co.cherrl appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this 1 (''day of I 1..1
,20 23
No C '
Seal Yexpiresy Co) 2-02(o M commission
Julie H Christian
NOTARY PUBLIC
NoFrth County
a
My Commission Expires July 6,2026
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