HomeMy WebLinkAboutNCC230903_FRO Submitted_20230403Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 P73434 - Salem Woods Mainline Extension
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
N/A
2. Location of land -disturbing activity: County Alamance City or Township Haw River
Salem Church Road 35°58'22.8" N 79°18'39.6" W
Highway/Street Latltude(decimal degrees) 35.973' Longltude(decimai degrees)-79.311°
3. Approximate date land -disturbing activity will commence: April 15, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility - Linear
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.50 Ac.
6. Amount of fee enclosed: $ 300 . 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 Staci Rogge E-mail Address staci.l.rogge@dominionenergy.com
Phone: Office # N/A
Mobile # 804-381-8398
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT - DIVISION 7, DISTRICT 1
Name
PO Box 776, 115 East Crescent Square Dr
Phone: Office # Mobile #
NCDOT Maintained R/W
Current Mailing Address Current Street Address
Graham NC 27253
City
State Zip
City
State
Zip
10. Deed Book No. 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 thelandowner(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
City State
Phone: Office #
andrew.moore@dominionenergy.com
E-mail Address
800 Gaston Road, Building A
Current Street Address
28053 Gastonia NC 28056-9486
Zip City
Mobile # 704-718-4114
State
Zip
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 #0519077)
Name of Registered Agent
160 Mine Lake Ct Ste 200
Current Mailing Address
Raleigh NC 27615
City State Zip
CT-StateCommunications@wolterskluwer.com
E-mail Address
160 Mine Lake Ct Ste 200
Current Street Address
Raleigh NC 27615
City
Phone: Office # 302-777-0204 Mobile #
Attn: Sherry McGinnes (Project ID #P73434)
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:
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.
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, P.E. Director - Engineering & Construction
Type r print ame
Signature
Title or uthor' y
2, 2� 2.023
Date
I, Ci A Y) '1 I (A Ayo raA b a Notary Public of the County of Gas ko n
State of North Carolina, hereby certify that AhareAA M Cat 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 ZT day of 20 '2 3
C,�- H -
CYNTHIA M. ALVARADO No ry
S aI NOTARY PUBLIC L
Gaston County My commission expireslU�� bCr -4 W25
North Carolina
My Commission Expires 1 o_ 1 ' ZS
Table 1
P73434 - Salem Woods Mainline Extension
Dominion Energy North Carolina
Alamance County, North Carolina
S&ME Project No. 23350005
TABLE 1: LANDOWNERS
Property
Identification
Deed
Deed
Landowner
Number (PIN)
Mailing Address
Book
Page
Bradley Dixon
158271
2254 Union Ridge Road,
4425
0517
Burlington, NC 27217-8613
Elaine Knighten Williamson
158272
4819 Salem Church Road,
4126
0605
Haw River, NC 27258-9795