NCC220642_FRO Submitted_20220204

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. Hwy 401 Assemblage 401 GME
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Garner
Highway/Street Hwy 401 Latitude 35.6688120 Longitude-78.6952120
3. Approximate date land -disturbing activity will commence: December 2021-January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Installation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.0
Express:$1250
Standard: $ 500
6. Amount of fee enclosed: _$Total:$1750 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per 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). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes No Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andrew Moore E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Right -of -Way N/A N/A
Name
Telephone Fax Number
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State
Zip City State Zip
10, Deed Book No. N/A
Page No. N/A 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, INCORPORATED [e-mail]
Name
E-mail Address
P.O. 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
Telephone [phone] 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 #0070179) [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
Telephone [phone] Fax Number 803-217-7810
(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:
Kleinfelder [e-mail]
Engineering Firm or other consultant E-mail Address
Keely Lane 910-233-8858
Individual contact person (type or print) 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
Type print name
Signature
Director — Engineering & Construction
Title or Authority
_ I A b12-ji22
Date
a Notary Public of the County of -GLa Y-)
State of North Carolina, hereby certify that tjndYew M('tyL 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 J0 day of 20 2 2
CYNTHIA M. ALVARADO Notallry
Se I NOTARY PUBLIC �`
Gaston County My commission expires_0L Ub2Y - , 1702fj
North Carolina
My Commission Expires A 0 ,' 2