NCC222202_FRO Submitted_20220614

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 NIA in the blank.)
Part A.
1. Project Name Four Oaks US 301 - Phase A
2. Location of land -disturbing activity: County Johnston City or Township Four Oaks
US 3011NC 96 35.47704-78.37693
Highway/Street Latitudesd��a�a�ea,> Longitude{aodmaidea�eesy
3. Approximate date land -disturbing activity will commence; July 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.654 Ac.
6. Amount of fee enclosed $700 . The Express Permitting application fee is a dual charge
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJoshua Lanaville
Phone: Office # 919-223-4279
E-mail Address Joshua,[e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT, Dist 3, Div 4
Name
2671 US 70 West
Current Mailing Address
Goldsboro, NC 27530
919-739-5300
Phone: Office #
Current Street Address
Mobile #
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) 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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies)
Piedmont Natural Gas Company Inc. [e-mail]
Company 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
Phone: Office # Mobile #
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:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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
(d) If 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
Engineering firm or other consultant
Michael Young
Individual contact person (type or print)
[e-mail]
E-mail Address
9199810310 9194126479
Phone: Office # Mobile #
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
corrected information should there be any change in the information provided herein.
Jeremy Koster VP NG Strategic Operations
Type print name
Signbiture
Title or Authority
S- 3 i - 20 '2
Date
1, Yt � ` t- WA , a Notary Public of the County of a_�kn �U
State of North Carolina, hereby certify that k V09S'V' appeared personally
before me this day and being duly sworn acknowledged t the above form was executed by him/her.
Witness my hand and notarial seal, this day of , 20
SHANNON L. WALL 4�4
Notary Public, North Caro'ine Notary
Mecklenburg County
M Commission Expires
eaJune 28, 2022 My commission expires l

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Fomn for multiple
owners. Attach copies of this page as needed to list all landowners.
I
Landowner 2 of Record:
MARSHALL WAYNE STRICKLAND
Name
Phone: Office # Mobile #
PO BOX 192
3575 US HWY 301
Current Mailing Address
Current Street Address
BLOUNTS CREEK, NC 27814-0192
SMITHFIELD, NC 27577
City State
Zip
City State Zip
Deed Book No. 03034
Page No 0105 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed_
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed
to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #