HomeMy WebLinkAboutNCC221349_FRO Submitted_20220408FINANCIAL 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. DENC - Weddington Road
1. Project Name
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street
Weddington Rd/ George W. Liles.Latitude P" N 035.398275 Longitude W080.657118
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Utility Installation
(2.5 AC (previously submitted)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0. 5 AC (new area) ) = 3. o AC
6. Amount of fee enclosed: $ $195 (Previously submitted) 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andrew Moore E-mail Address andrew.moore@dominionenergy.com
Telephone 704-810-3259 Cell # NSA Fax # NSA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT - ROW - Division 10 - District 1 (704) 983-4400 (704)982-3146
Name Telephone Fax Number
615 Concord Road (NC-73) 615 Concord Road (NC-73)
Current Mailing Address Current Street Address
Albemarle, NC 28001 Albemarle, NC 28001
City State Zip City State Zip
10. Deed Book No. NCDOT ROW Page No. NSA 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@dominionenergy.com
Name E-mail Address
P.O. Box_13,98_ 800_Gaston Road, Building A
Current Mailing Address Current Street Address
Gastonia, NC 28053-9486 Gastonia, NC 28056 -9486
City State Zip City State Zip
Telephone 704-810-3259 Fax Number 803-2'17-7810
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:
N/A
N/A
Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State Zip
City State Zip
Telephone N/A
Fax Number N/A
(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
andrew.moore@dominionenergy.com
Name of Registered Agent
E-mail Address
160 Mine Lake Ct. Suite 200
160 Mine Lake Ct. Suite 200
Current Mailing Address
Current Street Address
Raleigh, NC 27615
Raleigh, NC 27615
City State Zip
City State Zip
Telephone 704-810-3259 Fax Number 803-217-7810
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 Director — Engineering & Construction
Type o print name
Signature
Title or Autho ity
, /" Z"z
Date
yyk-, -k cr ,VC3ar c o a Notary Public of the County of Q a S b r--�
State of North Carolina, hereby certify that h0ay f-UJ Q 001 e— 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 0-0 UOL LAA 20 2 2
CYNTHIA M. ALVARADO
NOTARY PUBLIC No ry
al Gaston County
North prolinp c be r `�� lzUGS
My Commission Expires p� -- 25 My commission ex ires