NCC216870_FRO Submitted_20211213

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 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 NIA in the blank.)
Part A. PNG McLeansville Publix Extension
1. Project Name
2. Location of land -disturbing activity: County Guilford City or Township McLeansville
Highway/Street Birch Creek Road Latitude 36005'05"N Longitude 79039'36"W
1 Approximate date land -disturbing activity will commence: Fall 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Energy
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.5 AC
$1,890[6 ac x $65
6. Amount of fee enclosed: $ * 6 AC 9250a . 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 Jimmy Brown E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9_ Landowner(s) of Record (attach accompanied page to list additional owners):
Public RIW - NCDCT
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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 an an attached sheet):
Piedmont Natural Gas Company, Inc. [e-mail]
Name E-mail Address
PO Box 33068 4729 Piedmont Row Drive
Current Mailing Address Current Street Address
Charlotte NC 28233 Charlotte NC 28210
City State Zip City State Zip
Telephone [phone] 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:
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
Name of Registered Agent
160 Mine Lake Court, Ste 200
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephone [phone]
�II1
E-mail Address
same
Current Street Address
City State Zip
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:
W.K. Dickson & Co., Inc.
Engineering Firm or other consultant
Matthew D. Bare
[e-mail]
E-mail Address
[phone]
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.
Kevin Sell
Type or print name
Signature
Operations Manager
Title or Authority
6 -23- zoz 1
Date
Matthew D. Bare a Notary Public of the County of Mecklenburg
State of North Carolina, hereby certify that Kevin Sell appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
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