NCC215208_FRO Submitted_20210916

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 and/or
fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name M-201 Exposure West of Doggett Grove Road
2. Location of land -disturbing activity: County Rutherford City or Township Cool Springs
Doggett Grove Road 35°17'8.09" N 81°51'39AT' W
Highway/Street Latitude 35.2856' Longitude-81.8609'
3. Approximate date land -disturbing activity will commence: August 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Repair of exposed gas line
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.67 acres
Express: $5 0
6. Amount of fee enclosed: $ Tot l: $63o30 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name A. Robert Schwartz, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 803-530-7172 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. See Attached page No. See Attached Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
PUBLIC SERVICE COMPANY OF NORTH CAROLINA, INCORPORATED [e-mail]
Name E-mail Address
P.O. Box 1398 800 Gaston Road, Building A -
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28056-9486
City State Zip City State Zip
Telephone [phone] Fax Number 803-217-7810

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
CT Corporation System (NCSOS ID #519077)
Attn: Andrew Moore (Project ID #0069245) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200
Current Mailing Address
Raleigh
City
Telephone [phone]
NC 27615
State Zip
160 Mine Lake Ct Ste 200
Current Street Address
Raleigh NC 27615
City State Zip
Fax Number 803-217-7810
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
S&ME, Inc.
Engineering Firm or other consultant
Liane R. Morgan, P.E.
[e-mail]
E-mail Address
704-523-4726
704-525-3953
Individual contact person (type or print) Telephone 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.
Andrew Moore, P.E.
Typ or print name
Signature
Director - Engineering & Construction
Title or Authority
q/"7 2-1
Date
I, i,U1 1�t V(X r(1 U , a Notary Public of the County of 1 ,t- S
State of North Carolina, hereby certify that A3ntn
dnPA)� 1 t 1 (RJre 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 2L
CYNTHIA M. ALVARADO Rotoy
Se I NOTARY PUBLIC O Lam— ZS
Gaston County My commission expires
North Expires,
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