NCC233081_FRO Submitted_20231013

Check if this project is ARPA-funded
Attach a copy of the Letter of Intent to Fund
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 NCGO1 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 Line 122 Distribution Rebuild
`/f this project involves American Rescue Plan Act (ARPA) funds, list the Project Name or Project
Number(e.g . SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI)
2. Location of land-disturbing activity: County Bertie City or Township Kelford
Highway/StreetGriffins Quarter RoadLatitude(ded�idegmei 5682678 Longitude(decimaI degrees'-85 5680461-
3. Approximate date land-disturbing activity will commence: July 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial (Utility)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 3.4
6. Amount of fee enclosed: $ ($100 X 4) = $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 Ilt) Enclosed X No 11,
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name Justin Andrews E-mail Address Justin Andrews@duke-energy corn
Phone Office# n/a Mobile# [phone]
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Piedmont Natural Gas Company, Inc_ [phone] n/a
Name Phone Office# Mobile#
4720 Piedmont Row Drive 4720 Piedmont Row Drive
Current Mailing Address Current Street Address
Charlotte NC 28210 Charlotte NC 28210
City State Zip City State Zip
10 Deed Book No. See attached Page No See attached 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.) lf 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(ies).
Piedmont Natural Gas Company, Inc. n/a
Company Name E-mail Address
4720 Piedmont Row Drive 4720 Piedmont Row Drive
Current Mailing Address Current Street Address
Charlotte NC 28210 Charlotte NC 28210
City State Zip City State Zip
Phone: Office# [phone] Mobile# n/a
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 [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court, Ste 200 n/a
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 n/a
City State Zip City State Zip
Phone: Office# 919-844-8360 Mobile# n/a
Karen Rozar
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 n/a
Name of Registered Agent E-mail Address
n/a n/a
Current Mailing Address Current Street Address
n/a n/a
City State Zip City State Zip
Phone: Office# n/a Mobile# n/a
n/a
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.
n/a
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.
Amber Lineback GM Distribution Construction
Type or print name Title or uthority
Sig lire di Date
I, la.41.‘f , a Notary Public of the County of L.)
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 � � , 20 23
Nota
r.. n--r Rafnn L agienn
'` ) PUBIJC
My commission expires /7 4 23
UMy Commission Expires November 04,2023

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 9 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#