NCC241224_FRO Submitted_20240422

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Pitt Solar - Phase D
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Pitt City or Township Bethel
Big Oak Rd. 35.803572 -77.342892
Highway/Street LatltUde(decimal degrees) LongItUde(decimal degrees)
3. Approximate date land-disturbing activity will commence ASAP
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Solar Facility
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):49.73
6. Amount of fee enclosed $3,500 . 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. 15.45 disturbed acres previously paid for this phase area under
Project#:PITT-2023-036
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 Bradley Fite E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
CHARLIE L MANNING III
Name Phone: Office# Mobile#
7599 MAIN ST 7599 MAIN ST
Current Mailing Address Current Street Address
BETHEL NC 27812 BETHEL NC 27812
City State Zip City State Zip
10. Deed Book No. 1802 Page No 511 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).
Pitt Solar, LLC [e-mail]
Company Name E-mail Address
595 Summer Street, 4th Floor 595 Summer Street, 4th Floor
Current Mailing Address Current Street Address
Stamford CT 06901 Stamford CT 06901
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
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:
Cogency Global, Inc N/A
Name of Registered Agent E-mail Address
212 S. Tryon St, Ste 1000 212 S. Tryon St, Ste 1000
Current Mailing Address Current Street Address
Charlotte NC 28281 Charlotte NC 28281
City State Zip City State Zip
Phone: Office# [phone] 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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
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.
N/A
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.
Kenny Habul Manager / CEO
Type or print name Title or Authority
-16—a
Signature Date
I. ,)/tUDI7 OpiittA .TL,11tM C( , a Notary Public of the County of P C(
State of North Carolina, hereby certify that \( ;t,-64, appeared personally
before me this day and being duly sworn acknowledged thate above form was executed by him/her.
Witness my hand and notarial seal, this 2P day of f C-OVl , 20
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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.