NCC230638_FRO Submitted_20230313

FINANCIAL RESPONSLBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person ma. y 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 Piedmont Natural Gas Dan Valley HDD Road Relocation Protect_
2, Location of land -disturbing activity: County.Rockingham City or Township Madison
Highway]Street NWater St.. Latitude (decimal degrees) 36.392487°N. Longitude (decimal degrees) -79:952863°W
3. Approximate date land -disturbing activity will commence: February..
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5, Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.57
6. Amount of fee enclosed`.$ .400 . 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 ® No ❑
8. Person to contact should erosion and sediment. control issues arise during land -disturbing activity:
Name Shaun Huneycutt _ E-mail Address Shaun. Huneycuttp_duke-energy.com
Phone: Office # 704-438-0036 Mobile # NIA
9.. Landowner(s) of Record (attach accompanied page to list additional owners);
Ruben Berkley Mitchell III NIA NIA
Name Telephone Fax Number
. 1324 River Road NIA
Current Mailing Address Current Street Address
Pine Hall NC 27042 NIA
City State Zip City State. Zip
10. Provide a copy of the most current deeds — See attached.

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 names) of the owner(s) may be: listed as the financially responsible party(ies),
Piedmont Natural Gas Company, Inc. Daniel. Deese(c7duke-energy:com
Company Name E-mail Address
4720 Piedmont Row Drive 4720 Piedmont Row Drive.
Current Mailing Address Current Street Address
Charlotte NC 28210 Charlotte NG 28210
City State Zip City State Zip
Phone:. Office # NIA Mobile ## [phone]
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:
CT Corporation System .NIA
Name of Registered Agent E-mail Address
150 Fayetteville Street
Current Mailing Address
Raleigh NC 27601
City State Ziip
.NIA
Current Street Address
City
Phone; Office #` 919-821-7139 Mobile# NIA
Karen Rozar
Name of Individual to Contact (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:
NIP,
Name of Registered Agent E-mail Address
Current.Mailing Address
City
Phone. Office #
.State, Zip
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.
NIA
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was .provided
by rime 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.
Daniel Deese Proiect Manager
Typ or print name Title or Authority
Signature. Date
a Notary Public of the County of �al - e U
State of North Carolina, hereby certify that �- 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 �' day of Q� e 'l ; 20 '
$HANNoN L. WALL
Ng#ar Public, North Carolina
0 cklenburg County
My Commission Expires
June 28. 2027
wv�
Notary
My commission expires a-7

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(s) of Record:
ON
3
Alwiiner Collins
Name
1048 Christmas PI
Current Mailing Address
Greensboro NC 27410
City State Zip
Deed Book No.. 744 Page No. S
Roger_L. Smith and Linda L. Smith
Name
Route Z_ Box 24E
Current Mailing Address -
NIA NIA
Telephone Fax Number
N/A
Current Street Address
NIA
city State Zip
NIA NIA
Telephone. Fax Number
NIP,
Current Street Address
Stoneville NC 27048 NIA
City State Zip City State Zip
Deed Book No, 779 Page No. 243
Sod Farm Property LLC
Name
3036'Greenhouse Road
Current. Mailing Address
NIA NIA
Telephone Fax Number
Current Street Address
Winston-Salem NC 27127
City State Zip City State Zip
Deed Book No. 1171 Page No....1761