NCC223703_FRO Submitted_20221031

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name DENC Eva Drive
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Eva Drive/McGill Ave/Sign Dr 35.415048-80.614320
Highway/Street LatltUde(decimal degrees) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: Fall 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): 7.0
6. Amount of fee enclosed: $ 700.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bob Lepsic
Phone: Office # N/A
E-mail Address [e-mail]
Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached Sheet N/A N/A
Name
N/A
Current Mailing Address
N/A
City State Zip
Phone: Office # Mobile #
N/A
Current Street Address
N/A
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) 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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
PUBLIC SERVICE COMPANY OF NORTH CAROLINA, INCORPORATED
Company Name
P.O. Box 1398
Current Mailing Address
Gastonia NC 28053
City State Zip
Phone: Office # 704-810-3259
[e-mail]
E-mail Address
800 Gaston Road, Building A
Current Street Address
Gastonia NC 28056-9486
City State Zip
Mobile # N/A
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 (NCSOS ID #519077) Attn: Sherry McGinnes [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
Phone: Office # 302-777-0204 Mobile # N/A
Sherry McGinnes
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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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.
N/A
Company DBA Name
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.
Andrew Moore Director — Engineering & Construction
Typjq or print name Title or Authority
A'j l6 2oZ2
SYgnature Date
I, �

Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
See Attached Sheet
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
See Attached Sheet
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
City State Zip City
Deed Book No. Page No.
State Zip
Provide a copy of the most current deed.
Landowner 4 of Record:
See Attached Sheet
Name
Phone:
Office # Mobile #
Current Mailing Address
Current Street Address
City State
City
Zip
State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
See Attached Sheet
Name
Phone:
Office # Mobile #
Current Mailing Address
Current Street Address
City State
City
Zip
State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #
N/A
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #
N/A
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #
NIA
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #

DENC Eva Drive - Temporary Construction Easement & Permanent Easement Land Owners
Owner Name
Parcel ID
Deed Book/Page
Status
David M. Caudill
5610-8987-080000
1400/25
Negotiations in
progress
Concord Retail Investment Group, LLC
5610-8897-310000
13537/227
Negotiations in
progress
Public Service Company of NC
5621-0020-710000
1274/177
Owned
Andino's Metal Recycling, Inc
5620-0953-510000
1604/173
Negotiations in
progress