NCC217054_FRO Submitted_20211228

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 Johnson Pond Subdivision Gas Main Extension
2. Location of land -disturbing activity: County Wake City or Township Fuguav-Varina
35°37'13.08"N 78°45'50.40"W
Highway/Street Whiffed Road (SR-1407) Latitude 35.6203' Longitude-78.7640°
3. Approximate date land -disturbing activity will commence: January 15, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility - Linear
5. Total acreage disturbed or uncovered including off -site borrow and waste areas): 3.2 acres
Express: $1 00
Reqular: $400
6. Amount of fee enclosed: $Total$: 1A00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 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 # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Highway Division 5, District 1
Name
1575 Mail Service Center
Current Mailing Address
919-733-3213
Telephone
4009 District Drive
Current Street Address
919-715-5778
Fax Number
Raleigh NC 27699-1575 Raleigh NC 27607
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.
Name
[e-mail]
E-mail Address
P.O. Box 1398 800 Gaston Road, Building A
Current Mailing Address Current Street Address
Gastonia NC 28053
City
State Zip
Gastonia NC 28056-9486
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
E-mail 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 #0070848)
Name of Registered Agent
160 Mine Lake Ct Ste 200
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
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
Matthew H. Kunkle, P.E.
Individual contact person (type or print)
[e-mail]
E-mail Address
704-523-4726
Telephone
704-525-3953
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. Director - Engineering & Construction
Typ r print me Title or Au hority
flul2. 2-2.1
Signature Date
NL�VolrA_, a Notary Public of the County of
State of North Carolina, hereby certify that Nhrir ea'j iM on f P 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 8+1_ day of a bXn be,r , 20 2
CYNTHIA M. ALVARADO A
LIC No
S I NOTARY PUB
Gaston County 2 ®
North Carolina My commission expires � � cl2
My Commission Expires 1-Z