NCC221230_MODIFICATION Supporting Documents_20220816 (4)

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. PNG-Line 142 Buffalo Road Main Extension
1. Project Name
K
3
Location of land -disturbing activity: County Johnston
Highway/Street Covered Bridge Rd, Buffalo Rd Latitude 35.69199
City or TownshipArcher Lodge
Longitude-78,37275
Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.); utility (natural gas)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.3
6. Amount of fee enclosed: $ 100 The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Joshua Lanaville E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)-
NCDOT rights -of -way
Name Telephone Fax Number
Current Mailing Address Current Street Address
City
State Zip
10. Deed Book No. NCDOT page No.
City
State
Zip
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.
Piedmont Natural Gas Company, Inc [e-mail]
Name
250 Five Points Road
Current Mailing Address
Dudley NC 28333
City
State Zip
Telephone [phone]
E-mail Address
4720 Piedmont Row Drive
Current Street Address
Charlotte, NC 28210
City State Zip
Fax Number

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
City
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 [e-mail]
Name of Registered Agent
160 Mine Lake Court Suite 200
Current Mailing Address
Raleigh NC 27615
City State
Telephone [phone]
E-mail Address
Current Street Address
Zip City State Zip
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.
Jeremy Koster
4tT,per print name
ure
VP NG Strategic Operations
Title or Authority
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Date
I,�'hCMtl6n • • WaY , a Notary Public of the County of l NevrLbi buy
State of North Carolina, hereby certify that -eve_OsJe appeared
personally before me this day and being duly sworn knowledged that the above form was
executed by him.
Witness my hand and notarial seal, this
` SHANNON L. WALL '•
Notary Public, North Carolina .1
N1�bI �pburg County
My commission Expires
June 28, 2022 n
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day of 20- %V*
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Notary
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