NCC215727_FRO Submitted_20211014

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 NIA in the blank.)
Part A.
1. Project Name Amazon Main
2. Location of land -disturbing activity: County Johnston City or Township Smithfield
Highway/Street SR 1501, US 70 Bus., SR 191a Latitude 35.5606760 Longitude -78.3780430
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.92 Ac.
6. Amount of fee enclosed: $ 1575.00 . 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 No Enclosed Yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jason Bingham E-mail Address [e-mail]
Telephone cell # 919-222-8147 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT, Dist 3, Div 4 919-739-5300
Name Telephone Fax Number
2671 US 70 West
Current Mailing Address Current Street Address
Goldsboro, NC 27530
City State Zip City State Zip
10. Deed Book No, Right -of -Way Page No. 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.
Piedmont Natural Gas [e-mail]
Name E-mail Address
250 Five Points Rd 4720 Piedmont Row Drive
Current Mailing Address Current Street Address
Dudley, NC 28333 Charlotte, NC 28210
City State Zip City State Zip
Telephone 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:
NIA
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:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Alpha & Omega Group [e-mail]
Engineering Firm or other consultant E-mail Address
Michael Young 919-981-0310 x115
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.
Jason Dean Bingham Distribution Project Specialist
Type or prinj name Title or Authority
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I, T Y a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the abov rm was executed by him.
Witness my ha�r tariai seal, this 0 day of 20
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