NCC230668_FRO Submitted_20230404

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 PNG- DIMP CP Section 16
2. Location of land-disturbing activity: County Lenoir City or Township Kinston
Cunningham Rd,Greenleaf Rd 35.48722 -77.93944
Highway/Street Latltude(decimai degrees i Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: Dee 2$22- FEg 1023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): natural gas utility
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5'49
6. Amount of fee enclosed: $600 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 Logan Peede E-mail Address [e-mail]
Phone: Office# 252.639.7240 Mobile#
9 Landowner(s)of Record (attach accompanied page to list additional owners).
roadway rights-of-way
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No ROW 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)maybe listed as the financially responsible party(ies).
Piedmont Natural Gas A-140, L i n�'b et( eireil ti-toivt
Company Name E-mail Address
4720 Piedmont Row Drive q1219 f/fd/ütI - c) py,
Current Mailing Address Current Street Address
Charlotte NC 28210 Chiwoffe AJ C
City State Zip City State Zip
Phone: Office# 252.639.7240 Mobile# qa)" 2 25 " q/g f
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:
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)
(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:
CT Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Phone: Office# 844.252.0698 Mobile#
Karen Rozar
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.
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Ty e or print n me Title or Authority
i at� ��ilnL1U 1 17 V�Z3
g re Date •
I, Aq.kez_ LenigikAP, . a Notary Public of the County of CAA'‘CAN._,
I
State of North Carolina, hereby certify that.,- Q,A.-Q- --dk_ 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 tL 1.xa� , 20 Z3
DJ aatry
i ( 114 2-3
Raffle Laglenne My commission expires
$Pi; NOTARY PUBLIC
Union Counts NC
My Commission Expires November 04,2023
t

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:
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
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 4 of Record:
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 5 of Record:
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

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# 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 E-mail Address
Current Mailing 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#