NCC233541_FRO Submitted_20231201

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: Trinity Substation
2. Location of land-disturbing activity: County: Union City or Township: Monroe
Highway/Street Walters Mill Rd Latitude 34° 50'14.7" Longitude -80°30'48.3"
3. Approximate date land-disturbing activity will commence: September 1, 2019_
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 9.79 ac_
6. Amount of fee enclosed: $650.00. 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). SEE PREVIOUS SUBMITTAL
FOR FEE PAID
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Nathan Bass, PLA E-mail Address [e-mail]
Telephone [phone] Cell# [phone] Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Union Electric Membership Corporation [phone]
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. 5397 Page No. 070 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 greq.andressAunion-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. (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:
Gregory S.Andress greq.andress(a)union-power.com
Name of Registered Agent 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

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.
Gregory S. Andress Executive VP and General Manaqer
Type o nt name C Title or Auth rity
Signature Date
I, Pc 9j e..A 3 - , a Notary Public of the County of Lte
State of North Carolina, hereby certify thatG�Se90 S ( c' - es5 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 3 day of , 20 ate,
Oft-tA�
Notary
ANGEL%aFTHOMPSON i C
15, 20,3-�
NOTARY PUBLIC My commission expires
Union County
State of North Carolina
My Commission Expires December 15, 2026