NCC230515_FRO Submitted_20230227

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 53 Replacement
2. Location of land -disturbing activity: County Edgecombe City or Township Tarboro
Highway/Street NC122, SR 1207. SR 1212 Latitude(dadmai degrees) 35.893914 Longitude(dedmal degrees)-77.591408
3, Approximate date land -disturbing activity will commence: February 13, 2023
a. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.71 AC.
& Amount of fee enclosed 2,100 . 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, afterwhich 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJoshua Lanaville E-mail Address [e-mail]
Phone: Office # 919-223-4279 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT, Div 4, Dist 1
Name Phone: Office # Mobile #
14194 Hwy 903
Current Mailing Address Current Street Address
Halifax, NC 27839
City State - Zip City State Zip
10. Deed Book No. Right -Of -Way 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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(les).
Piedmont Natural Gas Company, Inc.
Company Name
250 Five Points Rd
Current Mailing Address
Dudley, NC 28333
City State Zip
Phone: Office #
[e-mail]
E-mail Address
4720 Piedmont Row Drive
Current Street Address
Charlotte, NC 28210
City �} State Zip
Mobile # �� U2 �r
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 forthe 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:
NIA
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
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
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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.
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;
Alpha & Omega Group
Engineering firm or other consultant
Michael Young
Individual contact person (type or print)
[e-mail]
E-mail Address
9199810310 9194126479
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.
Amber Lineback
Typefor print name
GM Distribution Construction
Title or Authority
_Jdngaq Z�1?A7.-5
Date
v , a Notary Public of the County of l nl'or%-
State of North Carolina, hereby certify that,appeared personally
before me this day and being duly sworn ackndwledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of �-c �t , 20 23
al
RalneLayerms NotaryNOTARY PUBLIC
tJ MCOUMy NC My commission expires N )207-3
My Ummisslm Expims November 04, 2021

Continued from Items 9 & 10 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:
Edgecombe County
Name
Phone: Office # Mobile #
PO Box 10
3005 Anaconda Rd
Current Mailing Address
Current Street Address
Tarboro, NC 27886
Tarboro, NC 27886
City State
Zip City State Zip
Deed Book No. 1188
Page No. 0564 Provide a copy of the most current deed.
Landowner 3 of Record:
LS Cable & System USA, Inc.
Name
Phone: Office # Mobile #
2801 Anaconda Rd
2901 Anaconda Rd
Current Mailing Address
Current Street Address
Tarboro, NC 27886
Tarboro, NC 27886
City State
Zip City State Zip
Deed Book No.1659
Page No. 1197 Provide a copy of the most current deed.
Landowner 4 of Record:
MIDATLANTIC WAREHOUSE & STORAGE II LLC
Name
Phone: Office # Mobile #
PO BOX 7233
2601 ANACONDA RD
Current Mailing Address
Current Street Address
ROCKY MOUNT NC 27804 Tarboro, NC 27886
City State
Zip City State Zip
Deed Book No. 1514 Page No. 0241 Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Current Mailing Address
City State Zip
Phone: Office # Mobile #
Current Street Address
City State Zip
Deed Book No, Page No. Provide a copy of the most current deed.

Continued from Item 1 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.
Company 2 Name
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Company 3 Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #