NCC242052_FRO Submitted_20240708

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 Environment and Natural Resources. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name: Line 2021 230 kV Rebuild
2. Location of land-disturbing activity: County: Pasquotank, Camden, Currituck City or Township
Start: 36.314034 Start: 76.225868
Highway/Street: Multiple-See Appendix C Latitude Terminus: 36.382876 Longitude Terminus: 76.080006
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
Transmission line(private utility)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10.3 miles
6. Amount of fee enclosed: $715 . The application fee of$65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount(Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: CJ Schleicher E-mail Address: [e-mail]
Telephone Cell#[phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Virginia Electric and Power Company d/b/a
Dominion Energy North Carolina Telephone Fax Number
Name
5000 Dominion Boulevard Same as mailing address
Current Mailing Address Current Street Address
Glen Allen VA 23060
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Dominion Energy North Carolina
c/o Kevin Fields, Authorized Representative [e-mail]
Name E-mail Address
5000 Dominion Boulevard Same as mailing address
Current Mailing Address Current Street Address
Glen Allen VA 23060
City State Zip City State Zrp

Telephone[phone] Fax Number
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
Kevin Fields [e-mail]
Name of Registered Agent E-mail Address
5000 Dominion Boulevard Same as mailing address
Current Mailing Address Current Street Address
Glen Allen VA 23060
City State Zip City State Zip
Telephone[phone] Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Kevin Fields Director, Project Management
Type or print name Title or Authority
Jul 1, 2024
Signature Date
I, L..DJARA 1 �ti� NA) CCU' S , a Notary Public of the County of ►-1 C-
Vr �\ Y1, Gi
State of NortfrC slim, hereby certify that v r1 1-. A appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this day of ,‘) , 20' -`\
I_
_41
Laura Paige Meadows Ne;tary
ti.I Commonwealth of Virginia,
f?, Notary Public
q:• Commission No.7937791 My commission expires ( 3 I [ )S
My Commission Expires 8/31/2025