NCC242297_FRO Submitted_20240731

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Anson Industrial Park— PDEMC Southeast Campus Expansion
2. Location of land-disturbing activity: County Anson City or Township Lilesville
Highway/Street_9825 US-74 East
Latitude(decimal degrees)_34.949902 Longitude(decimal degrees)_-79.903497
3. Approximate date land-disturbing activity will commence: June 2024 (ASAP)
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial_
5. Total acreage disturbed or uncovered (including off-site borrow and waste) 6.86_Acres
6. Amount of fee enclosed_$2,450.00 . The Express Permitting application fee is a dual charge. The
normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In
addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed Ll No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Joe Kindley, GC E-mail Address, [e-mail]
Phone: Office# 910-997-3153 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_Pee Dee Electric Membership Corporation 704-694-2114
Name Phone: Office# Mobile#
_9825 US-74 East 9825 US-74 East
Current Mailing Address Current Street Address
Lilesville NC 28091 Lilesville NC 28901
City State Zip City State Zip
10. Deed Book No._1237 Page No. 329 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).
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Company Name / E-mail AfidresS
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Current Mailing Address Current Street Address
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City State Zip City State Zip
Phone: Office# 7Oy-6.4 y— — not>S Mobile# 70 Y - /' -5- ZJ 773
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:
Do.-tag ki, SpIV�y ds, i' 'ey ® G�p�c .
Name of Registered)\gent E-mail Address
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Current Mailing Address Current Street Address
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City State Zip City State Zip
Phone: Office# 7 ' Lo'* — '7b $ Mobile# Li77-3
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:
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)

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering firm or other consultant E-mail Address
Individual contact person (type or print) Phone: Office# Mobile#
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.
LCJn 161 i . S,QiV t o ChiC- OsCr C.‘er
Type or print name J I Title or Authority
c2Yel'ed
Signature Date
I, A'rlq e,I c.. C. 1\11,k.34-of-. , a Notary Public of the County of A NS OY\
State of North Carolina, hereby certify that Dor\aAel N- SeWt_c1 appeared personally
before me this day and being duly sworn acknowledged that the above fdrm was executed by him/her.
Witness my hand and notarial seal, this 13 ' day of Tu.rs . , 20 p•Y
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