NCC241874_FRO Submitted_20240618

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 Dominion Energy North Carolina 0067772 US-70 Mebane Gas Pipeline Extension
Melville Township,Town of Haw River,Town of Haw River ETJ,City of Mebane,
2. Location of land-disturbing activity: CountyAlamance City or Township City of Mebane ETJ
US Hwy 70 36°5'49.719" N 79°18'45.774"W
Highway/Street Latitude(decimal degrees)36.097 Longitude(decimal degrees)-79.313
3. Approximate date land-disturbing activity will commence: (August 15,2022) May 13,2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Utility-Linear
(Total acreage Includes removal of a section of the previous alignment) 4.8 ac(original) +7.0 ac(modifcation#1) = 11.8 ac
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): +4.8 ac(modification#2) = 16.6 ac
Original$325 regular( d.)+$1,250 express(pd.)+ $455 Mod#1 (pd.) +0.2 ac(modification#3) = 16.8 ac
Modification#2 $500(pd.)+Modification#3g�1 00( d.)+Modifica ion#410 0.3 ac(modification#4)= 17.1 ac
6. Amount of fee enclosed: $2.630.00(pd.) + $100.00 . The a application tee of$1U0.0U per are (round
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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Robert Turnbull E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Highway Division 7, District 1 336-570-6833
Name Phone: Office# Mobile#
PO Box 766 115 East Crescent Square Drive
Current Mailing Address Current Street Address
Graham NC 27253 Graham NC 27253
City State Zip City State Zip
10. Deed Book No.NCDOT R/W 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
PO Box 1398 800 Gaston Road, Building A
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28053
City State Zip City State Zip
Phone: Office# 704 718 4114 Mobile#
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#0067772) [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#
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:
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 prin am Title orlAut ority
Mt 5/(2 202-4
Signature Date
I, 0,9Ylitnla_ M IN\Varaco , a Notary Public of the County of SitTY
State of North Carolina, hereby certify that PdYcW fqc re, 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 �Q 1 day of VAC - J , 20 24
4...........................-.......—.—....................4 x•-A—j2:- Li ' lai
i CYNTHIA M. ALVARADO Weary
Seal NOTARY PUBLIC '
I Gaston County
North Carolina ► My commission expires 10 19...0�5
I My Commission Expires jo 7•ZS

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:
City of Mebane-Public Works Department 919-563-3401
Name Phone: Office# Mobile#
106 E.Washington Street 636 Corregidor Street
Current Mailing Address Current Street Address
Mebane NC 27302 Mebane NC 27302
City State Zip City State Zip
Deed Book No.City R/W 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.