NCC230588_FRO Submitted_20230307

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 NIA in the blank.)
Part A.
1. Project Name Jacksonville Line 110, Piney Green Road Distribution Main
2. Location of land -disturbing activity: County OnSlow City or Township Jacksonville
Piney Green Rd; Sneads Ferry Rd 34.71508-77.3204
Highway/Street Latitude{decirnal degrees} Longltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: October, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.7
6. Amount of fee enclosed: $ 1 ,300.00 . 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 x❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Logan Peede E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT, Dist 1, Div 3 910.467.0501
Name Phone: Office # Mobile #
295-A Wilmington Hwy
Current Mailing Address Current Street Address
Jacksonville NC 28540
City State Zip City State Zip
10. Deed Book No. RNA/ Page No. Provide a copy of the most current deed.

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Fart B.
T. 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 name(s) of the owner(s) may be listed as the financially responsible party(ies).
Piedmont Natural Gas
Company Name
401 Executive Parkway
Current Mailing Address
New Bern NC 28562
City State
Phone: office # [phone]
[e-mail]
E-mail Address
Current Street Address
Zip City State
Mobile # [phone]
Sri
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
Name of Registered Agent
160 Mine Lake Ct. Ste 200
[e-mail]
E-mail Address
Current Mailing Address Current Street Address
Raleigh NC 27615
City
State Zip City
Phone: office # 844.252.0698
Karen Rozar
Mobile #
Name of Individual to Gontact (if Registered Agent is a company)
State Zip
(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:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

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:
United States of America [phone]
Name
Phone: Office # Mobile #
1510 Gilbert Street
Current Mailing Address
Current Street Address
Norfolk VA
23811-2738
City State
Zip
City State Zip
1
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Phone: Office # Mobile #
Name
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 4 of Record:
Phone: Office # Mobile #
Name
Current Mailing Address
Current Street Address
City
Deed Book No._
Landowner 5 of Record:
Name
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
State Zip
Provide a copy of the most current deed.

(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
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.
Jeremy Koster
Type or print name
Si*atre
VP, Strategic Operations
Title or Authority
10/3/20
Date
I,_�2 t4.io a n a NotaryPublic of the County of
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledge that the above form was executed by him/her.
Witness my hand and notarial seal, this �t
lNotary Public
waCounty
11
`) arth Carolina
MXCa s areq 7/24!:T24ll1
day of , 20 as
Notary
My commission expires Z-J Za at)-24

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ENERGY LAND & INFRASTRUCTURE, LLC • NASHVILLE, TN 37217
is it • IrblyL.,
DATE
INVOICE NO
COMMENT
AMOUNT
-
10/18/2022
DATE 10/18/22
OCT1822
PO# 9088854 APPLICATION FEE
VENDOR NCDEQ WILMINGTON REGIONAL OFFICE
TOTAL
1,300.00
1,300.00
ENERGY LAND & INFRASTRUCTURE, LLC FIRST BANK 67-932 0001017
1420 DONELSON PIKE, SUITE A-12 FRANKLIN, TN sal
NASHVILLE, TN 37217
[phone]
One Thousand Three Hundred and no1100
DATE AMOUNT
10/18/22 1017 $1,300.00
PAY NCDEQ WILMINGTON REGIONAL OFFICE
ORDER 127 CARDINAL DRIVE 8
OF WILMINGTON NC 28405
AUTHORIZED SIGNATURE

ENERGY LAND & INFRASTRUCTURE, LLC • NASHVILLE. TN 37217
0001017
DATE
INVOICE NO.
COMMENT
AMOUNT
NETAMOUNT
10/18/2022
OCT1822
PO# 9088854 APPLICATION FEE
1,300.00
DATE 10/18/22 VENDOR NCDEQ WILMINGTON REGIONAL OFFICE
TOTAL
1,300.00

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