NCC240152_FRO Submitted_20240119

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 P73403-Benson Road VA Clinic Gas Main Extension
2. Location of land-disturbing activity: County Wake City or Township Garner
2630 Benson Road 35'39'13.8"N 78°36'50.8"W
Highway/Street Latitude(decimal degrees) 35.6538' LongitUde(decimal degrees) -78.6141
November 20, 2023
3. Approximate date land-disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Linear
9.4 acres
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):
xp ress:
Regular: S1,000
6. Amount of fee enclosed Total: S3,000 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). 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 Staci Rogge E-mail Address [e-mail]
Phone: Office# N/A Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Highway Division 5, District 1 N/A N/A
Name Phone: Office# Mobile#
1575 Mail Service Center 4009 District Drive
Current Mailing Address Current Street Address
Raleigh NC 27699 Raleigh NC 27607
City State Zip City State Zip
NCDOT R/W
10. Deed Book No. Page No. N/A _ 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)may be listed as the financially responsible party(ies).
Public Service Company of North Carolina, Incorporated [e-mail]
Company Name E-mail Address
800 Gaston Road,Building A 800 Gaston Road, Building A
Current nn.,:i:..,.AddressMaing Current Street Address
Gastonia NC 28056 Gastonia NC 28056-9486
City State Zip City State Zip
Phone: Office# 704-718-4114
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 System(NCSOS ID#0519077)
Attn:Sherry McGinnes(Project ID#P73gp3) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office#302-777-0204
Mobile# N/A
Sherry McGinnes
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.
Dominion Energy North Carolina
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
S&ME, Inc.
[e-mail]
]mei1lGCVfTI
Engineering firm or other consultant E-mail Address
Matthew H. Kunkle, PE 704-523-4726 803-924-5523
Individual contact person (type or print) Phone: Office# Mobile#
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
Typ or print name Title or Authorit
1 115 Zo 23
Signature Date
I, U1
)114`rl l fk 11. RAYQra J u , a Notary Public of the County of CTCN kG ti
State of North Carolina, hereby certify that Yx,re�w Iv, UUY
I ` 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 iJO/LI/Vi ka , 20 �-:3
A
I
e-0--,---1-e---- H
CYNTHIA M. ALVARADO No , �� _.L-s 0,
( r
1 NOTARY PUBLIC y
Gaston County
S4Il CommiNo the aroliina 1_26 , My commission expires tO i 1 2C 2`J

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6,h Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR 122.22]
Per NC General Statute 143-215.68(i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
❑✓ I am the person responsible for the construction activities of this project,for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
n The information submitted in this NOI is,to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
n I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
n If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
n I hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): P73403-Benson Road VA Clinic Gas Main Extension
Specific Lot Numbers (must match Alb): N/A
Permittee (must match 81): Public Service Company of North Carolina, Incorporated
Legally Responsible Person (must match 82& 83): Andrew Moore, P.E
Title of Legally Responsible Person (must match B3b): Director Engineering &Construction
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person: N/A
Phone Numb r: 704.718.4114
! I 15 2L)Z3
Signature of Legally sponsible Person or Authorized Individual ate
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president,secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,Section B,
Item(6)of the NCG010000 permit.