NCC222270_FRO Submitted_20220620

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 andl
or fax information unavailable, place NIA in the blank.)
Part A. PNG Southern States Replacement
1. Project Name
2. Location of land -disturbing activity: County Rowan City or Township Cleveland
Highway/Street US Hwy 70 Latitude N 35.7179540 Longitude W 80.642519"
3. Approximate date land -disturbing activity will commence: Summer/Fall 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Installation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.0
6. Amount of fee enclosed: $ 195.00 . 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 Khalid Boston E-mail Address [e-mail]
Telephone [phone] Cell # NIA Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Right -of -Way NIA NIA
Name
NIA
Current Mailing Address
NIA
city
16. ❑eed Book No. NIA
Telephone
NIA
Fax Number
Current Street Address
NIA
State Zip City State Zip
Page No. NIA 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.
Duke Energy (Piedmont Natural Gas) [e-mail]
Name
4301 Yancey Rd
Current Mailing Address
Charlotte, NC 28217
City State
Telephone [phone]
E-mail Address
4301 Yancey Rd
Current Street Address
Charlotte, NC 28217
Zip City
Fax Number NIA
State
Zip

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
NIA
Name
NIA
Current Mailing Address
NIA
City State zip
Telephone NIA
NIA
E-mail Address
NIA
Current Street Address
NIA
City State Zip
Fax Number NIA
(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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
City State Zip
Telephone NIA
121/.1
E-mail Address
NIA
Current Street Address
NIA
City State Zip
Fax Number NIA
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.
Khalid Boston
Type or print name
K
Signature
Distribution Project Specialist
Title or Authority
5-ZZ-207-
Date
I,__kMkN
%V, , a Notary Public of the County of i
State of North Carolina, hereby certify that wrl WD appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of Mk( , 201—
v IA
JONATHON PRATHER Notary
SOTARY PUBLIC
ldenburg County
North Carouna My commission expires_ WEM 3
MY Commisalon Expiresr sw. o3, 2023

Additional landowners:
1. Cynthia Graham
217 Barber Junction Rd
Cleveland, NC 27013-9774
DB: 17-E, PG: 71, PIN:270-091
2. Robert & Mary Steele
222 Ivy i_n
Mocksville, NC 27028
DB: 1321, PG:208, PIN: 270A035
3. Cargill Incorporated
15407 McGinty Road W
Wayzata, MN 55391-0000
DB: 1296, PG: 945, PIN: 270-037