NCC215343_FRO Submitted_20210929

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6tn Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
® I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
x❑ The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information.
® I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
® If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
® I hereby request coverage under the NCGO10000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project: Baytree Lane Natural Gas Main Extension
Legally Responsible Organizational Entity: Public Service Company of North Carolina, Inc.
Ily Responsible Person: Andrew Moore
Title of Legally Rpponsible Persgp: Diroor - Engineering & Construction
*Signature: Date:
*Print Name and Title of Signed if 4thorized
Individual Differs from Permittee:
Phone Number: 704-810-3259
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.

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 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 Baytree Lane Natural Gas Main Extension
2. Location of land -disturbing activity: County Wake City or Township Bartons Creek Township
33° 55' 12.00" N 780 39' 49.20" W
Highway/Street 209 Sandhurst Road Latitude 35.92° Longitude-78.65°
3. Approximate date land -disturbing activity will commence: September 13, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Linear
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.71 acres
Express: $750
Regular:
$56. Amount of fee enclosed: $ : 94The 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 Bobby Ley, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 803-201-2539 Fax' # 803-217-7810
9. Landowner(s) of Record (attach accompanied page to list additional owners):
North Carolina Department of Transportation 919-220-4700
Name Telephone Fax Number
815 Stadium Drive N/A
Current Mailing Address Current Street Address
Durham NC 27704
City State Zip City State Zip
10. Deed Book No. NCDOT ROW Page No. N/A 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):
Public Service Company of North Carolina, Inc. [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 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:
CT Corporation System (NCSOS ID #0519077)
Attn: Andrew Moore (Project ID #0070968) [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
Telephone [phone] 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
Erik L. Hartwick
[e-mail]
E-mail Address
704-523-4726, Ext. 11607 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
Typepr print name
Signat
Director - Engineering & Construction
Title or Authority
911 /2p z 1
Date
Av4ti i. M �\/a Q a Notary Public of the County of R-o0 I U n
State of North Carolina, hereby certify that 1 m& tw I Y Lae- 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 2
CYNTHIA M. ALVARADO No "
Se I NOTARY PUBLIC �-,\ t , �1
Gaston County My commission expiresu_ 1 U Y10_,f
North Carolina
My Commission Expires-t0