NCC216321_FRO Submitted_20211112

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 N/A in the blank.)
Part A. Lexington 64 Solar Farm
1. Project Name
0A
3.
4.
5.
6.
Location of land -disturbing activity: County Davidson city or Township Lexington
Highway/Street Kepley Road (SR-2260) Latitude 35.783924, Longitude-80.137427
Approximate date land -disturbing activity will commence: October 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Solar Farm
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 41 Acres
Amount of fee enclosed: $ 2,000+$2,665=$4,665. 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
A
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Clay Holliday E-mail Address [e-mail]
Telephone [phone] Ext. 733 Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Three Hat Mountain Farming, Inc
Name
Telephone Fax Number
6182 E. US Hwy 64
Same
Current Mailing Address
Current Street Address
Lexington NC 27292
Same
City State Zip
City State Zip
10. Deed Book No. 539 Page No. 776 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):
Strata Clean Energy Holdings, LLC
[e-mail]
Name
E-mail Address
800 Taylor Street, Suite 200
Same
Current Mailing Address
Current Street Address
Durham NC 27701
Same
City State Zip
City State Zip
[phone]
Telephone
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 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.
Markus Wilhelm Manager
Type o print name Title or Authority l
S ur Date
a Notary Public of the Countyof
State of North Carolina, hereb ertify that S �t�} w%&Ak„ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this _day of roe 20�_
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Notary
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