NCC243274_FRO Submitted_20241024

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: South McCaskey Road (Williamston Dominion Energy Transmission Building)
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name below under which
you applied for funding through the Division of Water Infrastructure (DWI).
Is Project ARPA Funded ARPA Project Name ARPA Project#
No
2. Location of land-disturbing activity: County: Martin City or Township: Williamston
Highway/Street: S McCaskey Rd Latitude: 35.838682 Longitude:-77.070109
3. Approximate date land-disturbing activity will commence: 11/4/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.32
6. 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).
7. Has an erosion and sediment control plan been filed? No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Shelley Parekh E-mail Address: [e-mail]
Phone: [phone] Mobile:
9. Landowner(s)of Record:
Landowner(s) of Record
Name Email Business Phone Mobile Phone
Virginia Electric And Power Company [e-mail] 803-543-9582
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
120 Tredegar Richmond Virginia 23319 2601 N. Main Street South Virginia 24592
Street Boston

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).
Primary Financially Responsible Party
Company Name Email Business Phone Mobile Phone
Virginia Electric And Power Company [e-mail] 803-543-9582
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
120 Tredegar Richmond Virginia 23319 2601 N. Main South Virginia 24592
Street Street Boston
Additional Financially Responsible Parties
Company Name Email Business Phone Mobile Phone
Virginia Electric And Power Company [e-mail] 803-543-9582
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
120 Tredegar Richmond Virginia 23319 2601 N. Main South Virginia 24592
Street Street Boston
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:
Registered Agent Information
Name Email Business Phone Mobile Phone
Virginia Electric And Power Company [e-mail] 803-543-9582
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
120 Tredegar Richmond Virginia 23319 2601 N. Main South Virginia 24592
Street Street Boston
(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
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
'fr60 Mine Lake Court, Suite 200, in Raleigh, North Carolina 27615 same as physical address
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
Kimley-Horn shelley.parekh@kimley- 412-851-3511
Horn.com
Physical Address Mailing Address
Street 1 City State Zip Street 1 City _ State Zip
750 Holiday Pittsburgh Pennsylvania 15220 750 Holiday Pittsburgh Pennsylvania 15220
Drive, Suite Drive, Suite
750 750

(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 DBfi 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.
Kj LE M . 14.Qor) Aui- .l i €O REiPRESENT �4r1v�
Typeprint name Title or Authority
or
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Signat re Dat e
Cc
l�ct::r (Ze,�t5 , a Notary Public of the C...auMy of_(� c vt ntim C�
C r cv morl wes c v➢rrc-c rt i.‘--
tR-r4-1dnrtl3-Gerfllifta herby certify that r-ti '4 c 'l 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_S`)C F-c,6re.,% , 20 Th`�
Notary
My commission expires_
COURTNEY R. CLEMENTS
NOTARY PUBLIC
REGISTRATION#285563
COMMONWEALTH OF VIRGINIA
MY COMMISSION EXPIRES
March 31,j1 '

Additional Details
1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water
2. Was Express Review Requested: No
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.