NCC223651_FRO Submitted_20221031

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 and/
or fax information unavailable, place NIA in the blank.)
Part A. Lowesville Breaker Station
1. Project Name
2. Location of land -disturbing activity: County Lincoln City or Township Catawba Springs
Highway/Street N Pilot Knob Road Latitude 35.444688 Longitude-80.986530
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.4
6. Amount of fee enclosed: $130.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Judson Wortman E-mail [e-mail]
Telephone [phone] ext.416 Cell #
Fax ##
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rutherford Electric Membership Corporation 1-800-521-0920
Name
186 Hudlow Road
Telephone
828-248-2938
Fax Number
Current Mailing Address
Current Street Address
Forest City NC 28043
City State Zip
City State Zip
10. Deed Book No. 3076 Page No. 8S3-887 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.
Rutherford Electric Membership Corporation (REMC)
[e-mail]
Name
E-mail Address
PO Box 1569
186 Hudlow Road
Current Mailing Address
Current Street Address
Forest City NC 28043
Forest City NC 28043
City State Zip
City State -ZIP
Telephone [phone] ext.416
Fax Number 828-248-2938

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:
Elizabeth T. Miller
Name of Registered Agent
PO Box 1569
Current Mailing Address
Forest City NC 28043
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
186 Hudlow Road
Current Street Address
Forest City NC 28043
City State Zip
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.
Colon L. Saunders
Ty or print name
L , V J'x(v— --� �s
Signature
V.P. of Operations
Title or Authority
Date
1, /� * l�oo , a Notary Public of the County of JS Ak ('FQrd
State of North Carolina, hereby certify that CO aQ 2, SaC/rrders appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
T
Witness my hand and notarial seal, this 217' day of �Gfp e� 20 2.Z
_= NOTARY Notary
Seal
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