NCC241754_FRO Submitted_20240610

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 TCEMC - Pink Hill Transmission Line
Duplin and Lenoir Counties Pink Hill
2. Location of land-disturbing activity: County City or Township
Start Kitty Noerker Rd and Tapp Farm Rd Start 35.023279,End:35.030708 Start:-77.797167,End:-77.746243
Highway/Street Latitude Longitude
End:W Pleasant Hill Rd April
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Transmission Line
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.25
6. Amount of fee enclosed: $ SOO.00 . 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 NoX Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name TCEMC - Tony Grantham E-mail Address [e-mail]
Telephone[phone] Cell# [phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
TCEMC [phone]
Name Telephone Fax Number
PO Box 130 4255 Us Highway 117 Alternate
Current Mailing Address Current Street Address
Dudley, NC 28333 Dudley, NC 28333
City State Zip City State Zip
10. Deed Book No. 1969 Page No.902 Provide a copy oflthe most current deed.
Part B.
1. Company(ies) ,or; ,firrn(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.
TCEMC - Tony Grantham [e-mail]
Name E-mail Address
PO Box 130 4255 US Highway 117/AIte.rnat'e_-:;
Current Mailing Address • Current Street Address • `,
Dudley, NC 28333 Dudley, NC 28333
City State Zip City State ,; J 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:
J. Michael Davis [e-mail]
Name of Registered Agent E-mail Address
PO Box 130 4255 Us Highway 117 Alternate
Current Mailing Address Current Street Address
Dudley, NC 28333 Dudley, NC 28333
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.
Tony A. Grantham Manager of Engineering and Operations
Type or print name Title or Authority
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SignatU re Date
I, bOY VIGI&M.t l I`,IA , a Notary Public of the County of DtkpbAb
State of North Carolina, hereby certify that To V N. 6 YGI.VI� appeared
personally before me this day and being duly swot acknowledged that the above form was
executed by him. Ir ,r
Witness my hand and notarial seal, this day of 1��C , 20 o�,`f'
____
rSMITN,Ir? fItkAALL)A11411 3 1-tib.
4RY Notary
PUBLIC My commission expires 9114-'41(�q / ao��
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March 4, 2024
Rhonda Hall
Division of Energy, Mineral, and Land Resources
Department of Environmental Quality
127 Cardinal Drive Ext.,
Wilmington, NC 28405
Re: TCEMC— Pink Hill Transmission Line - Erosion Control Plan
Dear Rhonda:
Tri-County Electric Membership Corporation of North Carolina plans to build a new transmission
line per the submitted plans. Tony Grantham of Tri-County EMC is authorized to be the applicant
and sign all applications related to this project.
If you have any questions or need additional information, please advise.
Very truly yours,
Tri-County Electric Membership Corporation
By:
J. Michael Davis