NCC216059_FRO Submitted_20211123

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. (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.
Line 254 Clubhouse -Lakeview 230 kV Rebuild
1. Project Name
2. Location of land -disturbing activity: County Northampton and Halifax City or Township Roanoke Rapids
Multiple Start: 36.545254 ° N Start:-77.646646 ° W
Highway/Street Latitude Finish: 36.474635 ° N Longitude Finish:-77,670833 ° W
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Electric utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 24.94 acres
6, Amount of fee enclosed: $ $9625 & $2000 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 x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Mr. J Eric Clay E-mail Address James,[e-mail]
Telephone NIA Cell # 804-335-9534 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Multiple, see ESC Plans NIA NIA
Name Telephone
NIA NIA
Current Mailing Address
NIA
City State
10. Deed Book No. multiple
Current Street Address
NIA
Zip City
State
Fax Number
Zip
Page Na multiple 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):
Virginia Electric and Power Company d!b!a Dominion [e-mail]
Energy North Carolina Attn: Mark Allen
Name E-mail Address
10900 Nuckols Road, 4th Floor
Current Mailing Address
Glen Allen VA
City
10900 Nuckols Road
Current Street Address
23060 Glen Allen
State Zip City
VA 23060
State
Zip
Telephone [phone] Fax Number NIA

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:
CT Corporation System NIA
Name
E-mail Address
160 Mine Lake Ct, Ste 200
160 Mine Lake Ct, Ste 200
Current Mailing Address
Current Street Address
Raleigh, NC 27615-6417
Raleigh, NC 27615-6417
City State
Zip City State Zip
Telephone [phone]
Fax Number NIA
(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
N/A
Name of Registered Agent
E-mail Address
160 Mine Lake Cl, Ste 200
160 Mine Lake Ct, Ste 200
Current Mailing Address
Current Street Address
Raleigh, NC 27615-6417
Raleigh, NC 27615-6417
City State
Zip City State Zip
Telephone [phone]
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:
C2 Environmental, Inc.
Engineering Firm or other consultant
Jennifer B. Johnson
Individual contact person (type or print)
[e-mail]
E-mail Address
757-636-5047
Telephone
NIA
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.
Mark Allen
Type or print name
Director, PT Project Development & Execution
Title or Authority
I_X'P -�9 -z
Signature [late
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I, uaa F'pi _ (! CLA Leis a Notary Public of the County of i
iR't30—
State of Nor , hereby certify that Mc ek S. Allp, 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 10&� day 31= 24aLaura F�atge MOSGOWS
Commonwealth of mrginis
Notary Public My commission expires o2(31IQ025
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