NCC240018_FRO Submitted_20240110

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 Moriah Energy Center
2. Location of land-disturbing activity: County Person City or Township Rougemont/ Mt Tirzah
Helena Moriah Road g 36.268205 LOngltUde(decimaldegrees) -78.851430
Highway/Street Latitude decimal de rees
3. Approximate date land-disturbing activity will commence: 1/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 74.0
(74.100)+$2000=$9400
6. Amount of fee enclosed . 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 E Enclosed x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Staci Rogge E-mail Address [e-mail]
Phone: Office# 804-279-2906 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Christie Leigh Sparrow
Name Phone: Office# Mobile#
6470 Helena Moriah Road 4848 Helena Moriah Road
Current Mailing Address Current Street Address
Rougemont NC 27572 Rougemont NC 27572
City State Zip City State Zip
Page No. 86 10. Deed Book No. 149 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(ies).
Public Service Company of North Carolina,Inc [e-mail]
Company Name E-mail Address
PO Box 1398 800 Gaston Road, Building A
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28056-9486
City State Zip City State Zip
Phone: Office# 704-718-41 1 4 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:
CT Corporation System(NCSOS ID#0519077) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct. Ste 200 160 Mine Lake Ct. Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office#302-777-0204 Mobile#
Sherry McGinnes
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 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
(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:
HDR [e-mail]
Engineering firm or other consultant E-mail Address
Amber Liepse 629 228 7584
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.
Andrew Moore Director- Engineering and Construction
Type or print name Title or Authority
1/2/24
Signature Date
I, (1154C 1 lC , a Notary Public of the County of
State of North Carolina, heir.aby certify that COr .h Ok) MEOLO 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 2_ day of jO h(A r)/ , 20 24
KISHA R. HAYES k_ • Ha_up
NOTARY PUBLIC Notary
Mecklenburg County
o Carolina �1 My CommiExpires IIo)z/z4 My commission expires I U1 2_4

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:
Lisa Street Smith
Name Phone: Office# Mobile#
2806 Cheek Road 6105 HELENA MORIAH RD
Current Mailing Address Current Street Address
Durham NC 27704 ROUGEMONT NC 27572
City State Zip City State Zip
Deed Book No.716 Page No.499 Provide a copy of the most current deed.
Landowner 3 of Record:
Bernard Lee Day
Name Phone: Office# Mobile#
6258 HELENA MORIAH RD 6100 HELENA MORIAH RD
Current Mailing Address Current Street Address
ROUGEMONT NC 27572 ROUGEMONT NC 27572
City State Zip City State Zip
Deed Book No. 1152 Page No.704 Provide a copy of the most current deed.
Landowner 4 of Record:
Lillie Mae B Street Estate
Name Phone: Office# Mobile#
2806 CHEEK RD 4863 HELENA MORIAH RD
Current Mailing Address Current Street Address
DURHAM NC 27704 ROUGEMONT NC 27572
City State Zip City State Zip
Deed Book No. 181 Page No.774 Provide a copy of the most current deed.
Landowner 5 of Record:
Bernard Lee Day
Name Phone: Office# Mobile#
6258 HELENA MORIAH RD 6041 HELENA MORIAH RD
Current Mailing Address Current Street Address
ROUGEMONT NC 27572 ROUGEMONT NC 27572
City State Zip City State Zip
Deed Book No. 1 163 Page No.332 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:
Christie Leigh Sparrow
Name Phone: Office# Mobile#
6470 Helena Moriah Road 6633 Helena Moriah Road
Current Mailing Address Current Street Address
ROUGEMONT NC 27572 ROUGEMONT NC 27572
City State Zip City State Zip
Deed Book No. 1152 Page No.698 Provide a copy of the most current deed.
Landowner 7 of Record:
Larry Thomas Blalock
Name Phone: Office# Mobile#
224 Circle B Farm Road 224 Circle B Farm Road
Current Mailing Address Current Street Address
ROUGEMONT NC 27572 ROUGEMONT NC 27572
City State Zip City State Zip
Deed Book No. 1163 Page No.213 Provide a copy of the most current deed.
Landowner 8 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 9 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.