NCC222889_FRO Submitted_20220812

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Fresh Air Energy XXXVII, LLC
2. Location of land -disturbing activity: County Northampton _ City or Township Pleasant Hill
Highway/Street NC Hwy 48 Latltude(decimal degrees) 36.533643 LOngltude(decimal degrees)-77.549315
3. Approximate date land -disturbing activity will commence: 6/6/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): solar facility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 155 acres
6. Amount of fee enclosed: $15,500 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Cheyne Matheny E-mail Address [e-mail]
Phone: Office # [phone] Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ercelle K Harding N/A 252-537-0361
Name Phone: Office # Mobile #
1382 Lebanon Church Rd.
Current Mailing Address
Garysburg, NC 27831
Same as mailing
Current Street Address
City State Zip City
10. Deed Book No. 640 Page No._ 677
State
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(les).
Pine Gate Renewables, LLC [e-mail]
Company Name E-mail Address
130 Roberts St. 130 Roberts St.
Current Mailing Address
Asheville, NC 28801 Asheville, NC 28801
City State Zip City State Zip
Phone: Office # 828-820-2816 Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Ben Catt
Type or name
Signature
Authorized Person
Title or Authority
5. 9 - ZC)"
Date
1, C06 AVVI WUUk mv.nn _,a Notary Public of the County of
State of North Carolina, hereby certify that :5—P- rN CC. A' appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this
``X%J1111ri1��
IN
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G .yA PUBLIC 10,
�/., of COv0�.
day of 20 ji
Notary
My commission expires_ f4_�1� Td2`""

Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Phyllis Williams N/A 252-326-6522
Name
PO Box 31
Current Mailing Address
Pleasant Hill, NC 27866
City State
Deed Book No. 474
Landowner 3 of Record:
Blondie Key
Name
1000 Cornwallis Road
Current Mailing Address
Pleasant Hill, NC 27866
City State
Deed Book No. 474
Landowner 4 of Record:
Linda H Mayo
Name
P.O. Box 264
Current Mailing Address
Garysburg, NC 27831
City State
Deed Book No. 474
Landowner 5 of Record:
Phone: Office # Mobile #
3094 Hwy 301
Current Street Address
Pleasant Hill, NC 27866
Zip City State Zip
_ Page No. 626 Provide a copy of the most current deed.
N/A 252-536-4496
Phone: Office #
Same as mailing
Mobile #
Current Street Address
Zip City State Zip
Page No. 626 Provide a copy of the most current deed.
N/A
Phone: Office #
Same as mailing
Current Street Address
Zip City
Page No. 626
252-903-5343
Mobile #
State Zip
Provide a copy of the most current deed.
Shanice Seward N/A 252-532-2159
Name Phone: Office # Mobile #
3824 Heather View Lake Same as mailing
Current Mailing Address Current Street Address
Winston-Salem, NC 27127
City State Zip City State Zip
Deed Book No. 474 Page No. 626 Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 6 of Record:
Leota Ingram
N/A 919-422-9893
Name
Phone: Office # Mobile #
4608 Six Sibling Ct.
Same as mailing
Current Mailing Address
Current Street Address
Raleigh, NC 27610
City State
Zip
City State Zip
Deed Book No. 1070
Page No.
285 Provide a copy of the most current deed.
Landowner 7 of Record:
Cleveland Harding, Jr.
N/A 336-608-8038
Name
Phone: Office # Mobile #
4681 Kellys Trail Ct.
same as mailing
Current Mailing Address
Current Street Address
Winston-Salem, NC 27101
City State
Zip
City State Zip
Deed Book No. 1070
Page No.
285 Provide a copy of the most current deed.
Landowner 8 of Record:
Dexter Harding
N/A 336-817-2281
Name
Phone: Office # Mobile #
1416 Gracewood Lane
same as mailing
Current Mailing Address
Current Street Address
Kernersville, NC 27284
City State
Zip
City State Zip
Deed Book No. 1070
Page No.
285 Provide a copy of the most current deed.
Landowner 9 of Record:
Dulce Harding Phillips
N/A 561-307-0615
Name
Phone: Office # Mobile #
14575 80th Lane N.
Same as mailing
Current Mailing Address
Current Street Address
Loxahatchee, FL 33470
City State
Zip
City State Zip
Deed Book No. 1070
Page No.
285 Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 10 of Record:
SF Blue LLC
Name
2375 Woodlake Drive, Suite 380
Current Mailing Address
Okemos, MI 48864
City State
1072
Deed Book No.
Landowner 11 of Record:
517-908-0909
Phone: Office # Mobile #
same as mailing
Current Street Address
Zip City State Zip
Page No. 529 _ Provide a copy of the most current deed.
Niyah Brooks
N/A 252-432-3382
Name
Phone: Office # Mobile #
3420 Toledo Terrace, Apt 440
Same as mailing
Current Mailing Address
Current Street Address
Hyattsville, MD 20782
City State
Zip
City State Zip
Deed Book No. 1051
Page No.
855 Provide a copy of the most current deed.
Landowner 12 of Record:
Niles Brooks
N/A 252-430-9488
Name
Phone: Office # Mobile #
33 Woodbridge Ct.
Same as mailing
Current Mailing Address
Current Street Address
Henderson, NC 27537
City State
Zip
City State Zip
Deed Book No. 1051
Page No.
456 855 Provide a copy of the most current deed.
Landowner 13 of Record:
Howell Land and Timber Properties, LLC
Name
70 Rock Ridge Road
Current Mailing Address
Pittsboro, NC 27312
City State
Deed Book No. 1048
N/A 919-444-4067
Phone: Office # Mobile #
Same as mailing
Current Street Address
Zip City State Zip
Page No. 688 Provide a copy of the most current deed.

Continued from Item 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 3 Name E-mail Address Y
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Zip
Zip
Zip