NCC220447_FRO Submitted_20220125

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 and/or fax
information unavailable, place N/A in the blank.)
Part A.
1. 1. Project Name M121 Replacement Staging Yard
2. Location of land -disturbing activity: County_ Wake City or Township Raleigh
Highway/Street_ Hillsborough St _ Latitude_ 35.786325 N _ Longitude_-78.731811 W _
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Project Material Storage
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_2.3 acres
6. Amount of fee enclosed: $_300 + $750 Express Fee = $1,050. 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 $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is
$2,900).
7. Has an erosion and sediment control plan been filed? Yes X_ No Enclosed_X_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robert Ley, P.E. E-mail Address [e-mail] _
Telephone Cell # [phone] _ Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cary Land & Cattle LLC
Name
9105 Fawn Hill Ct
Current Mailing Address
Telephone
Fax Number
5917 Hillsborough St
Current Street Address
_ Raleigh, NC 27617 Raleigh NC 27606
City State Zip City State Zip
10. Deed Book No._ 012453 _ Page No._ 00287 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.
Public Service Company Of North Carolina. Inc andrew.moore(ildominionenergy com
Name E-mail Address
P.O. Box 1398
Current Mailing Address
Gastonia, NC 28053
City State Zip
Telephone [phone]
800 Gaston Road, Building A
Current Street Address
Gastonia, NC 28056-9486
City State Zip
Fax Number 803-217-7810

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
C ity
Telephone,
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(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:
CT Corporation System (NCSOS ID #519077),
Attn: Andrew Moore (Project ID #0069245) and rew mooreCcildominionenergv com
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200
Current Mailing Address
Raleigh, NC 27615
C ity State
Telephone [phone]
160 Mine Lake Ct Ste 200
Current Street Address
Raleigh, NC 27615
Zip City
Fax Number
State
803-217-7810
Zip
(c) In 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
Engineering firm or other consultant
Jonathan Gates
Individual contact person (type or print)
_ [e-mail]
E-mail Address
303-323-9525 NA
Telephone Fax Number
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.
_ Andrew Moore, P.E. Director - Engineering & Construction _
Type or rint name Title or Authority,
12/ld /20Z,
Signs ure Date
I, OAA lI1 ki d A(VQ rQQ['0 a Notary Public of the County of a­-a's' 'o
State 4of North Carolina, hereby certify that Av)&.eA,j Wouy-e_ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
L Witness my hand and notarial seal, this i day of'_PWC tjy o be {' 20 2
CYNTHIA M AL% RADO No
S I NOTARY PUBLIC {"
Gaston County My commission expires( V,ieX 25
North Carolina
My Commission Expires ( lr j - 2 5