NCC243279_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 NCG01 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: P74961 -Sherri Downs
*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).
PLEf2jiect ARPA Funded ARPA Project Name ARPA Project#
No
2. Location of land-disturbing activity: County: Wake City or Township: Angier
Highway/Street: 9904 Kennebec Church Road Latitude: 35.533300 Longitude: -
78.755400
3. Approximate date land-disturbing activity will commence: 10/21/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Other: Linear Gas pipeline
project
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.40
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: Robert Turnbull E-mail Address: robe rt.t.turnbuIl@domin ion energy.ccm
Phone: Mobile: [phone]
9. Landowner(s) of Record:
Landowners of Record
Name Email Business Phone Mobile Phone
NCDOT Division 5 District 1 Roadway Right of
Way
Ph sical Address Mailing Address
Street 1 city State Zip Street 1 city State Zip
9904 Kennebec Angier NC 27501 1575 Mail Service Raleigh NC 27699
Church Road Center
Name Email Business Phone Mobile Phone
NCDOT Division 6 District 2 Roadway Right of
Way
Ph sical Address Mailing Address
Street 1 city State zip Street 1 city State Zip
PO Box 1150 Fa ettville NC 28302 PO Box 1150 Fa ettville NC 28302

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 companyis a sole proprietorship orif 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 Part
Company Name Email Business Phone Mobile Phone
Public Service Company of North [e-mail]
Carolina, Incorporated
Physical Address Mailing Address
Street 1 city State Zip Street 1 city State Zip
800 Gaston Gastonia NC 28053 P.O. Box 1398 Gastonia NC 28053
Road, Building
A
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 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
CT Corporation System (NCSOS CT- 302-777-0204
ID#0519077); Attn: Sherry [e-mail]
McGinnes Project ID#P74961
Physical Address Mailing Address
Street 1 city State Zip Street 1 city State Zip
160 Mine Raleigh NC 27615 160 Mine Lake Ct Raleigh NC 27615
Lake Ct
(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
Ph sical Address Mailing Address
Street 1 city State zipStreet 1 Ci State Zip
En i eering/Consulting Firm Information
Name Email Business Phone Mobile Phone
S&ME atrick ibbons smeinc.com
Physical Address Mailing Address
Street 1 city State Zip Street 1 city State Zip
2016 Ayrsley Charlotte NC 28273 2016 Ayrsley Charlotte NC 28273
Town Blvd, Suite Town Blvd, Suite
2-A 2-A

Additional Details
1. Stream Classification: WS-IV: Water Supply IV
2. Was Express Review Requested: Yes
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.