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Home My WebLink AboutNCC241550_FRO Submitted_20240521 FINANCIAL RESPO NSIBILITY/O W PERSHIP FO RM SEDIM ENTATIO N PO LLUTIO NCO NTRO LACT No person m ay initiate any land-disturbing activity on one or m cre acres as covered by the Act, including any activity under a corn m m plan of developm ent of this size as covered by the NCG 01 perm t, before this form and an acceptable erosion and sedim entation control plan have been corn lieted and approved by the Land Q uality Section, N.C. Departm ait of Environm eital Quality. Subm t the corn Meted form to the appropriate Regional O fice. (Please type or print and, if the question is not applicable or the a-m al address or phone num her is unavailable, place N/A in the blank.) Part A. 1. Project Nam a M criah Energy Center *If this project involves Am erican Rescue Plan Act(ARPA)funds, list the Project Nam ebelow under which you applied for funding through the Division of Water Infrastructure (DWI). Is Project ARPA Funded ARPA Project Nam e ARPA Project# No 2. Location of land-disturbing activity: County: Person C ity or Township: Rougem cnt Highway/Street: 6401 Helena M criah Rd. Latitude: 36.268205 Longitude: - 78.851430 3. A pproxim ate date land-disturbing activity will corn m ewe: 6/1/2024 4. P urpose of developm ent (residential, corn m ecial, industrial, institutional, etc.): Industrial 5. T otal acreage disturbed or uncovered (including off-site borrow and waste areas): 74.00 6. T he application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Exam ile: 8.10-acre application fee is $900). 7. H as an erosion and sedim alt control plan been filed? No 8. P erson to contact should erosion and sedim ent control issues arise during land-disturbing activity: N am a Staci Rogge E -m al Address: staci.L.rogge@dom hionenergy.com Phone: 804.381.8398 Nb bile: 9. L andowner(s)of Record: Landow ner(s) of Record Name Email Business Phone Mobile Phone Larry Blalock Itblaclock@gm al.com Physical Address M sling Address Street 1 City State Zip Street 1 City State Zip 224 Circle B Farm Rougem cnt NC 27572 224 Circle B Farm Rougem cnt NC 27572 Road Road Name Email Business Phone Mobile Phone Bernard Day laday@em Largm al.com Physical Address M sling Address Street 1 City State Zip Street 1 City State Zip 6258 Helena Rougem cnt NC 27572 6258 Helena Rougem cnt NC 27572 M criah Road M criah Road Name Email Business Phone Mobile Phone Lillie M Street-Sm th I isastreet070@g m al.com Physical Address M sling Address Street 1 City State Zip Street 1 City State Zip 6105 Helena Rougem cnt NC 27572 6105 Helena Rougem ant NC 27572 M criah Road M criah Road Name Email Business Phone Mobile Phone Lisa Street Iisastreet070Agm al.com Physical Address M ailing Address Street 1 City State Zip Street 1 City State Zip 6105 Helena Rougem cnt NC 27572 6105 Helena Rougem cnt NC 27572 M criah Road M criah Road Part B. 1. Com pany(ies) who are financially responsible for the land-disturbing activity (Provide a corn prehensive 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 nam e(s) of the owner(s)may be listed as the financially responsible party(ies). Primary Financially Responsible Party Company Name Email Business Phone Mcbile Phone Public Service Corn pany of North andrew.m core@dom hionenergy.com Carolina, Inc Physical Address M sling Address Street 1 City State Zip Street 1 City State Zip 800 G a;ton G a;tonia NC 28056 PO Box 1398 G a;tonia NC 28053 Road Additional Financially Responsible Parties 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 subm I a draft erosion and sedim eitation control plan and to conduct the anticipated land disturbing activity. 2. (a) If the Financially Responsible Party is a domes tic company registered on the NC Secretary of State business registry, give nam e and street address of the Registered Agent: Registered Agent Information Name Email Business Phone Mcbile Phone Physical Address M ailing Address Street 1 City State Zip Street 1 City 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: North Carolina Agent Information Name Email Business Phone Mobile Phone CT Corporation System Cf- 302-777-0204 StateCom m unications@wolterskluwer.com Physical Address M ailing Address Street 1 City State Zip Street 1 City State Zip 160 M he Raleigh NC 27615 160 M he Lake Raleigh NC 27615 Lake Ct. Ct. Engineering/Consulting Firm Information Name Email Business Phone Mcbile Phone HDR Engineering am ber.liepse@hdrinc.com 1 -(629)-228-7500 , Physical Address M ailing Address Street 1 City State Zip Street 1 City State Zip 120 Brentwood Brentwood Please 37027 120 Brentwood Brentwood Please 37027 Com m ails Way Select Com m as Way Select Additional Details 1. Stream Classification: NSW: Nutrient Sensitive Waters; WS-III: Water Supply III; 0 RN: 0 Ltstanding Resource Waters 2. Was Express Review Requested: No The above inform ation is true and correct to the best of m y knowledge and belief and was provided by m eunder oath. (This form m Lst 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 instrum efts for the Financially Responsible Party). I agree to provide corrected information should there be any change in the inform Aion provided herein.