NCC232908_FRO Submitted_20230928

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Edgecombe Solar Gen-Tie Line
2. Location of land-disturbing activity: County Edgecombe City or Township
ALT HVVY 64 35.932561 -77.676269
Highway/Street Latitude(decimal degrees) Long itude(decimai degrees)
3. Approximate date land-disturbing activity will commence: 10/01/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Solar
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 9.82
6. Amount of fee enclosed 3000 . 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,after which 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❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael Kaplan E-mail Address [e-mail]
Phone: Office# 312-582-1293 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Penelo, LLC N/A
Name Phone: Office# Mobile#
1000 S Howard Circle N/A
Current Mailing Address Current Street Address
Tarboro, NC 27886
City State Zip City State Zip
10. Deed Book No. 1688 Page No.0711 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)maybe listed as the financially responsible party(ies).
Invenergy Solar Development North America [e-mail]
Company Name E-mail Address
One South Wacker Drive, Suite 1800 N/A
Current Mailing Address Current Street Address
Chicago, IL 60606 N/A
City State Zip City State Zip
Phone: Office# 312-582-1293 Mobile# N/A
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:
John Barefoot [e-mail]
Name of Registered Agent E-mail Address
421 Fayetteville Street, Suite 600 N/A
Current Mailing Address Current Street Address
Raleigh, NC 27601 N/A
City State Zip City State Zip
Phone: Office#919-653-5843 Mobile# N/A
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:
CT Corporation System N/A
Name of Registered Agent E-mail Address
160 Mine Lake Ct Suite 200 N/A
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# 877-858-3855 Mobile#
Jessica Malloy, POA
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:
Kimley-Horn [e-mail]
Engineering firm or other consultant E-mail Address
John Barefoot, PE 919-653-5843
Individual contact person (type or print) 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.
Michael Kaplan Vice President
Type or print e Title or Authority
3 ® - 2-
ignature Date
I, rvt.rrJertr , a Notary Public of the County of Codes
ltutrJOur
State of Nertth Carolina, hereby certify that �=IcvlaGt, kap LAN 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 3O"' day of AVGi UST , 20 2 3
�innewws
OFFICIAL SEAL „r, (
APRIL BENNETT
NOTARY PUBLIC STATE OF ILLINOIS
MY COMMISSION EXPIRES:10/08/24 Notary
Seal My commission expires OCrnrEZ. 8, Zo23

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 2 of Record:
HC Bourne Family Cox Farm LLC
Name Phone: Office# Mobile#
5021 Canopy Drive
Current Mailing Address Current Street Address
Marietta, GA 30066
City State Zip City State Zip
Deed Book No. 1629 Page No.0681 Provide a copy of the most current deed.
Landowner 3 of Record:
Brake Farms, Inc
Name Phone: Office# Mobile#
8400 Waynesboro Ct
Current Mailing Address Current Street Address
Raleigh NC, 27615
City State Zip City State Zip
Deed Book No. 1489 Page No.0458 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 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 Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#