NCC221867_FRO Submitted_20220517

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name_ Dominion Energy Services, Inc. on behalf of Atlantic Coast Pipeline LLC
2. Location of land -disturbing activity: County_ Northampton, Halifax, Nash, Wilson and Johnston
City or Township N/A --
Highway/Street —Latitude _360 32' 42.723"N (AP-1) Longitude _77030'29.66811 W_
Latitude _36°32'35.716"N (AP-2) Longitude _77°30'26.799"W—
Latitude_36°32'35.242"N (AP-3) Long itude_77030'25.975"W_
3. Approximate date land -disturbing activity will commence: September 2022
4.. Purpose of development (residential, commercial, industrial, institutional, etc.);_Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ 2,006 (original) + 9
(Mod #1) + 41 (Mod #2) — 11 (Mod #3) + 1 (Mod #4) = total acreage_2,046_
Previously permitted — 2046 acres; Undisturbed—1127.1 acres; Undisturbed -landowner felled —
17.44 acres new workspace — 0.84 acres
Acreage
Station Number
Workspace Type
0.14
1128+00
Full Restoration
0.15
2756+00
Tree Removal Only
0.20
2756+00
Tree Removal Only
0.35
2756+00
Access Areas - Right -of -Way
6. Amount of fee enclosed: (2,006 acres/$130,390 Original amount) + (9 acres/$585 Mod #1 amount (Feb.
2018)) + (41 acres/$2,665 additional) — (11 acres/$0) + (1 acres/$100 additional) = New Total Acreage
2,046/$133,640 (fee previously paid) + 1 Acre/$100.00 (new fee) = 2,047 Acres/$133,740.00 total. The
application fee for the new workspace ($100.00) is enclosed.
7. Has an erosion and sediment control plan been filed? Yes Z Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name —Andrew Dorman E-mail [e-mail]
Phone: Office # _804-219-7311 Mobile # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_N/A — see spreadsheet
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. N/A Page No. Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Atlantic Coast Pipeline, LLC
c/o Dominion Energy Services, Inc.
120 Tredegar Street
Richmond, VA 23219
Attention: Charlotte McAfee — Director Construction Projects
Charlotte. P.McAfee(a_dominionenergy.com
[phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Dominion Energy Services, Inc. on behalf of
Atlantic Coast Pipeline, LLC
Attn: Jason Ericson, Director Environmental Services
120 Tredegar Street
Richmond, VA 23219
Jason.p.ericson(&dominionenergy.com
[phone]
If any such notice requires legal service of process:
SERVE:
CT Corporation System
160 Mine Lake Court, Suite 200
Raleigh, NC 27615-6417
[phone]
On behalf of:
Atlantic Coast Pipeline, LLC
Attn: Jason P. Ericson, Director Environmental Services
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
CT Corporation
160 Mine Lake Court, Suite 200
Raleigh, INC 27615-6417
[phone]
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name

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(s)
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 Party). I agree to provide
c rrected information should there be any change in the information provided herein.
6t .II IdAi0k NU4 �
T)Telpr pri�j nar? Title or Authority
Siqnatu
-- A"' 1 �A)
Date
I, a Notary Public of the County of __RC'fYi,!2 o
_-1filn cam.
State of 1-4eILI I % a01 efit°ra; hereby certify that 2 L , ft)44e W- e - appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this r _day of r� � i ,202
Gina Lynn Ford
commonwealth of Virginia
Notary Public Notary
Emission No. 7862628
mission Expires 7t31l2024
My commission expires '7 13112024