NCC223963_FRO Submitted_20221206

August 31, 2022
Mr. Brian Lambe
Environmental Specialist
NCDEQ
127 Cardinal Drive Extension
Wilmington, NC 28405
Re: Tri County EMC Tapp Farm Breaker Station
Dear Mr. Lambe:
Tri-County Electric Membership Corporation of North Carolina plans to build a new breaker
station/substation per the submitted plans. Tony Grantham of Tri-County EMC is authorized
to be the applicant and sign all applications related to this project.
If you have any questions or need additional information, please advise.
Very truly yours,
Tri-County Electric Membership Corporation
By:
J Michael Davis

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 Tri-County EMC -Tapp Farm Breaker Station
2. Location of land -disturbing activity: County Duplin City or Township Smith Township
Kitty Noecker Road (SR 1704) 35.023278°-77.797449'
Highway/Street LatltUde�decima� degrees) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: November 30, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Electrical Substation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.544
6. Amount of fee enclosed: $ 400.00 . 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 TCEMC - Tony Grantham E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
TRI COUNTY ELECTRIC MEMBERSHIP CORPORATION [phone]
Name Phone: Office # Mobile #
P.O. BOX 130 4255 S U.S. 117 ALT HWY
Current Mailing Address Current Street Address
DUDLEY, NC 28333 DUDLEY, NC 28333
City State Zip City State Zip
10. Deed Book No. 1969 Page No. 902 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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
TRI COUNTY ELECTRIC MEMBERSHIP CORPORATION
Company Name
P.O. BOX 130
Current Mailing Address
DUDLEY, NC 28333
City State
Phone: Office # [phone]
Zip
[e-mail]
E-mail Address
4255 S U.S. 117 ALT HWY
Current Street Address
DUDLEY, NC 28333
City State Zip
Mobile # [phone]
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:
TRI-COUNTY ELECTRIC MEMBERSHIP CORPORATION
Name of Registered Agent
P.O. BOX 130
Current Mailing Address
DUDLEY, NC 28333
City
State
WE
[e-mail]
E-mail Address
4255 S U.S. 117 ALT HWY
Current Street Address
DUDLEY, NC 28333
City
Phone: Office # [phone] Mobile #
Michael J. Davis
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # 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.
Tony Grantham Manager of Engineering and Operations
Type or print name
Sign re
Title or Authority
Date
I, �ot�i/t(JLSI(!/1/r�ti/iI l� a Notary Public of the County of DOiYl
State of North Carolina, hereby certify that I Ott 61TLfl,rW1►(JLm appeared personally
before me this day and being duly sworn acknowledg d that tthheB above form was executed by him/her.
Witness my hand and notarial seal, this �I day of
jll
q Notary
(NOTAJRY�My commission expires
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