NCC215393_FRO Submitted_20210929

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
Noperson may initiate any land -disturbing activity onone nrmore acres as covered by the Act before
this form and mnacceptable erosion and sedimentation ountnd plan have been completed and approved
by the Land Quality Gection, 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 unavai|ab|a, place N/A inthe blank.)
Part A.
p8[fin Solar -L8ydOwnYard
1. Project Name
2. Location nfland-disturbing activity: County SUrFV —City orTownship Elkin
��lk'OVVii��ifm F�OB[j ��H"1��'O���"�� A0"^¢R'5A �z1"VV
Highway/Street ' '~ Latitude ~ ~ Longitude ~~ ~~-' ``
3. Approximate date land -disturbing activity will commence: ASAP
��O�[�V
4. Purpoeaofdeve|opmont(veoidentio|.00mmeroia|.industha|.inutbutione|.o�.)�^- ~'
5. Total acreage disturbed uruncovered (including of-ait7
off -site '5
G. Amount of fee enclosed: 2,520 The Express Permitting application fee is m dual charge.
The normal fee of$S5.00 per acre is aaaaoaed without a ceiling amount. In addition. the Express
Permitting supplement is $250.00 per acre up to eight moran, after which the Express Permitting
supplemental fee in mfixed $2.000.00 (Example: S acres total is $2.585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has anerosion and sediment control plan been filed? Yes No X�nu|oaed.^______
O. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Steve �'~x'OF E-mail Add
3 �-�1�A
Telephone ~~~~~ ~~ Cell #______ N/A
S. Londowner(s)ofRecord (attach accompanied page bolist additional ownens:
PET, LLC
N/A
Name Telephone Fax Number
210VV. MG'M Street
Current Mailing Address Current Street Address
Elkin, NC 28621
City State Zip City State Zip
10. Deed Book No. 1775 Page No. 191 Provide acopy ofthe most current deed.
PartB'
1Company(ies) or firm(s) 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 ofthe owner o/manager may bnlisted uuthe fihonniaKyresponsible party.
[]EPCOM Power Inc. lBO@l@depCUO0pOVVe[.CO[D
Name E-mail Address
9185 E Pima Center Pkxm/#1M[) 9185 E Pima Center Pkmv#1MD
Current Mailing Address Current Street Address
Scottsdale AZ 85258 Scottsdale AZ 85258
City
State Zip City
Telephone 70-391(] Fax N
sm

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:
Timmons Group (Derrick Johnson, PE) [e-mail]
Name
5410 Trinity Road, Suite 102
Current Mailing Address
Raleigh, NC 27607
City
State Zip
Telephone [phone]
E-mail Address
5410 Trinity Road, Suite 102
Current Street Address
Raleigh, NC 27607
City State Zip
Fax Number [phone]
(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:
Corporation Service Company
N/A
Name of Registered Agent
E-mail Address
2626 Glenwood Avenue, Suite 550
2626 Glenwood Avenue, Suite 550
Current Mailing Address
Current Street Address
Raleigh NC 27608
Raleigh NC 27608
City State Zip
City State Zip
Telephone [phone]
Fax Number N/A
(c) In 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:
Timmons Group
[e-mail]
Engineering Firm or other consultant
E-mail Address
Jacob Dooley, PE
919-866-4937
Individual contact person (type or print)
Telephone 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.
Type or print name
Signature
S2 IVVZ Vrc ,'.ec s�i�i✓�/T"
Title or Authority
D tae
a Notary Public of the County of 8AV-11wea
State ofI l w/hereby certify that IBC { LC� `� (L, appeared personally
before me this day and being duly sworn acknoxYvledged that the above form was executed by him.
Witness my hand and notarial seal, this _j_day of ) 20'
ROBYN HEISTER Notary
Notary Public - state or Arizona
MARICOPACOuNTy My commission expires 0 11C
91 G-0-q
Commission 0 582058
Expires March 15, 2024