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HomeMy WebLinkAboutNCC230462_FRO Submitted_20230216FINANCIAL 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 address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name East Carolina RNG Plant 2. Location of land -disturbing activity: County Bertle City or Township Snakebite 1922 Republican Road 36.114835-77.064400 Highway/Street_ LatltUde(decimaldegrees) Long ltUde(decimaldegrees) 3. Approximate date land -disturbing activity will commence: March 1, 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.9 acres 6. Amount of fee enclosed $3,400.00 . 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 per acre up to eight acres, afterwhich the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Jude Daudu, P.E Phone: Office # 346-708-8272 E-mail Address ldaudu@archaea.energy Mobile # 713-480-3858 9. Landowner(s) of Record (attach accompanied page to list additional owners): dba, East Carolina Environmental, Inc. (252)-348-3322 Name 1922 Republican Road Current Mailing Address Aulander NC 27805 n/a Phone: Office # Mobile # 1922 Republican Road Current Street Address Aulander NC 27805 City State Zip City State Zip 10. Deed Book No. 791.840 Page No. 763.853 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 companyis 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). Lightning Renewables, LLC Company Name 4444 Westheimer Road, Suite G450 Current Mailing Address Houston, TX 77027 bmccarthy@archaea.energy E-mail Address 4444 Westheimer Road, Suite G450 Current Street Address Houston, TX 77027 City State Zip City State Zip Phone: Office # 346-708-8272 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 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) (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: Corporation Service Company Name of Registered Agent E-mail Address 2626 Glenwood Ave, Ste 550 2626 Glenwood Ave, Ste 550 Current Mailing Address Current Street Address Raleigh NC 27608 Raleigh NC 27608 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 (d) If 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: Hodges, Harbin, Newberry, & Tribble, Inc. mcheek@hhnt.com Engineering firm or other consultant K. Matthew Cheek, P.E. Individual contact person (type or print) E-mail Address 478-743-7175 478-319-8853 Phone: Office # Mobile # 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. Brian McCarthy Typ r print n me Sig ature Manager Title or Authority 2-2 2 Date I, i46(rrrJ 3 a Notary Public of the County of %nrsyl.rz i r State of hereby certify that 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 ComT6raweaith of PCnnSYlvdRia Notary BLUEBERRY EMILY J KILLER - N rY Sea! Philadeip„a Coun:y nary Publit My CEB.Lion Expires April 2. 2025 Commission Humber 1394904 -2- day of f�-�n , 20 2 11 i4o" . I &j,( 4 t Notary Z My commission expires �' Z� S 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. Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 5 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Continued from Item 1 in Part 8 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 Current Mailing Address E-mail Address Current Street Address City State Zip City Phone: Office # Mobile # Company 3 Name Current Mailing Address E-mail Address Current Street Address City State Zip City Phone: Office # Mobile # Company 4 Name Current Mailing Address E-mail Address Current Street Address City State Zip City Phone: Office # Mobile # Company 5 Name Current Mailing Address E-mail Address Current Street Address State Zip State Zip State Zip City State Zip City State Zip Phone: Office # Mobile #