NCC216554_FRO Submitted_20211130

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 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 NameVirginia Line (Q403) Substation
2. Location of land -disturbing activity: County V V arren City or Township Nutbush
Highway/Street Latitude
7030 Drewry Virginia Line Rd, Manson, NC 27553 36.52351501-ongitude -78.2902950
3. Approximate date land -disturbing activity will commence: February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Substation/
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):XXX
6. Amount of fee enclosed: $XXX . 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. v
7. Has an erosion and sediment control plan been filed? Yes^ No Enclosed^ _
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameHugh Stephens
Telephone [phone]
E-mail Address [e-mail]
Cell # 678-735-8996 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
W. J. Renn Credit Sheffer Trust, Charles M. Davis Trustee 919-496-2137
Name
101 N. Church St. PO Box 798
Current Mailing Address
Telephone Fax Number
101 N. Church St. PO Box 798
Current Street Address
Louisburg NC 27459 Louisburg NC 27459
City State Zip City State Zip
10. Deed Book No.71 0 Page No.85 , Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(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.
Virginia Line Solar, LLC [e-mail]
Name E-mail Address
130 Roberts Street
Current Mailing Address
Asheville NC 28801
City
130 Roberts Street
Current Street Address
Asheville NC 28801
State Zip City
Telephone [phone] Fax Number
State
Zip

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
E-mail Address
Current Street Address
City State Zip City
Telephone _ Fax Number
State Zip
(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
Telephone.
State
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:
Booth & Associates, LLC [e-mail]
Engineering Firm or other consultant E-mail Address
Briana Eddy 919-851-8770 n/a
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.
Ben Catt
Type or print name
Signat . e
Authorized Person
Title or Authority
10/22/2021
Date
I, Qlli� Kv , a Notary Public of the County of JVuI OVA
State of North Carolina, hereby certify that Pw C att 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 Q a day of
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