NCC223105_FRO Submitted_20220902

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.-
1. Project Name Line 2064 X-Brace Replacement
2. Location of land -disturbing activity: County Currituck City or Township
Beginning: 36.390609' Beginning:-76.0588541
Highway/Street Shortcut Road (SR 158) Latitude(dearnaldegreesjnatng:35.386fa2° Longitude( ( g TaminaUng: 76.026447°
decimal de tees
3. Approximate date land -disturbing activity will commence: August 29, 2022
Transmission Line
4. Purpose of development (residential, commercial, industrial, institutional, etc.):. (private utility)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.95 acres
Normal Fee: $900
6. Amount of fee enclosed Express Fee: $2000 . 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 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2.000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name James Eric Clay E-mail Address [e-mail]
Phone: Office # 804-787-6380 Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Virginia Electric and Power Company d/b/a 804 355 9534
Dominion Energy North Carolina
Name Phone: Office #
10900 Nuckols Road, 4th Floor
Current Mailing Address
Glen Allen, VA 23060
Current Street Address
Mobile #
City State Zip City State Zip
A copy of the certified letter
notifying landowners is
10. Deed Book No.ernrJnged hetein Page No. Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page,) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the names) of the owner(s) may be listed as the financially responsible party(ies).
Virginia Electric and Power Company dlbla
Dominion Energy North Carolina [e-mail]
Company Name E-mail Address
10900 Nuckols Road, 4th Floor 10900 Nuckols Road, 4th Floor
Current Mailing Address Current Street Address
Glen Allen, VA 23060 Glen Allen, VA 23060
City State Zip City State Zip
Phone: Office # 804-529-9348 Mobile # NIA
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
CT Corporation System NIA
Name of Registered Agent E-mail Address
160 Mine Lake Court, Suite 200 160 Mine take Court, Suite 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office # 888-724-9870 Mobile # NIA
Robert Ingato (Secretary)
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
CT Corporation System NIA
Name of Registered Agent E-mail Address
160 Mine Lake Court, Suite 200 160 Mine Lake Court, Suite 200
Current Mailing Address Current Street Address
Raleigh, NC 27616 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office # 888-724-9870 Mobile # NIA
Robert Ingato (Secretary)
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. if the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Dominion Energy North Carolina
Company DBA Name
(d) If 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:
Dominion Energy North Carolina
Engineering firm or other consultant
Monica Young
[e-mail]
E-mail Address
910-232-7505
Individual contact person (type or print) Phone: Office # Mobile #
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Kevin Fields
Authorized Representative
Type or print n me Title or Authority
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Signature Date
[, w �P'Vhtr 14PMRAh , a Notary Public of the County of ( 5�
v"f'5 " n.vx
State of Carsala, hereby certify that v+n� 2 � appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this ! Lt day of A-Voi Jai , 20
Notary
Seal
.•� .0*NOTARY**•.2
f . PUBLIC
REG # 7946WO ; •C
MY CQMMISSION ; qC
6. EXPIRES
4/30/2025
My commission expires