NCC221109_FRO Submitted_20220323

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 and/or fax
information unavailable, place NIA in the blank.)
Part A.
1. Project Name SRNG Liberty RNG Facility
2. Location of land -disturbing activity: County Randolph City or Township n/a
Highway/Street Meredell Farm Rd Latitude 35°51'28"N Longitude-79°38'22"W
3. Approximate date land -disturbing activity will commence: February 8, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.67 ac
6. Amount of fee enclosed: $800 + $2000 . 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 $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900).
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 Jeff Smith, PE E-mail Address [e-mail]
Telephone [phone] Cell # 704-907-2214 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Koopman Dairies Inc 7046828161
Name Telephone Fax Number
204 Loyd Dr 204 Loyd Dr
Current Mailing Address Current Street Address
Statesville, NC 27298 Statesville, NC 27298
City State Zip City State Zip
10. Deed Book No. 23138 page No. 1364 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 sore
proprietorship, the name of the owner or manager may be listed as the financially responsible party.
SRNG Liberty, LLC [e-mail]
Name E-mail Address
1447 South Tryon Street, Suite 301
Current Mailing Address
Charlotte, NC 28203
City State Zip
1447 South Tryon Street, Suite 301
Current Street Address
Charlotte, NC 28203
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsi
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 oth
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Thomas & Hutton [e-mail]
Engineering firm or other consultant E-mail Address
Jeff Smith
Individual contact person (type or print)
704-907-2214
Telephone
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided by
under oath (This form must be signed by the Financially Responsible Person if an individual or his attorney
fact, or if not an individual, by an officer, director, partner, or registered agent with the authority to exec
instruments for the Financially Responsible Person). I agree to provide corrected information should there
any change in the information provided herein.
Rick WACOX
Type r p 'n name /
Sig ature
CEO
Title or Authority
4�a�llbz 2azz_
Date `
I a otary Public of the County of �
State of d 2 N<<, hereby certify that L %Lappeared person
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 , 20.9,&
f:k_i Lag
JOYCE JOHNSTON No6ry
A ARY PUBLIC - ARIZONA /� r _
1NARICOPA COUNTY r fV,�
COMMISSION # 20636 y commission expires — GJ
* z* My Comm. Exp.: March 26, 2026