NCC215347_FRO Submitted_20211008

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08042007
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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A. Perendale Holdings, LLC
1. Project Name g
2. Location of land -disturbing activity: County Davie city or Township Farmington
Highway/Street Pudding Ridge Road (SR-1435) Latitude 35.989718 Longitude-80.541382
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar Farm
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 49 Acres
6. Amount of fee enclosed: $ 3,185+2,000=5, t 85 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 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 an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Glenn McDonald
E-mail Address [e-mail]
`telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Charles Ray Howell & Sandra B. Howell
Name
Telephone Fax Number
181 Holly Lane
Same
Current Mailing Address
Current Street Address
Mocksville NC 27028
Same
City State Zip
City State Zip
10. Deed Book No. 0948 Page No 0360 provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Perendale Holdings, LLC
[e-mail]
Name
E-mail Address
11330 Vanstory Drive, Suite 101
Same
Current Mailing Address
Current Street Address
Huntersville NC 28078
Same
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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:
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
(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:
McKim & Creed, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Patrick Needham, PE 704-841-2588 704-841-2567
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.
L. Wayng Marshall Manager
Type r ri t naWe Title or Authority
1 i 1)-j
Signature Date
I, 6ral'a— V i l 1a.nuevo a Notary Public of the County of M ca/dolI�(�
State of North Carolina, hereby certify that L _(,,iyie, Akwshal appeared personally
before me this day and being duly sworn acknowledge that the above form was executed by him.
Witness my hand and notarial seal, this 1 2 _ _day of I ( �., 2© 2-1
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Seal IV )
coM 4SSMY Exf1fl�S U s My commission expires C?/�GCLd �2(4
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