NCC222753_FRO Submitted_20220802

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 and/
or fax information unavailable, place NIA in the blank.)
Part A. Line 229 Hathaway - Tarboro Rebuild Phase 1
1. Project Name
2. Location of land -disturbing activity: County Nash & Edgecombe City or Township N/A
multiple Start: 36.042596 Start:-77.753283
Highway]Street Latitude End: 35.964931 Longitude End:-77,672220
3. Approximate date land -disturbing activity will commence: August 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Electric Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 28'55
6. Amount of fee enclosed: $ 2'900 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 James Eric Clay E-mail Address [e-mail]
Telephone N/A Cell ## 804-335-9534 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Multiple, see attached NIA NIA
Name
NIA
Current Mailing Address
NIA
Telephone
NIA
Current Street Address
NIA
City State Zip City
10. Deed Book No. multiple Page No. multiple
Fax Number
State
Zip
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Virginia Electric & Power Company d/bla Dominion [e-mail]
Energy North Carolina c/o Kevin Fields
Name E-mail Address
10900 Nuckols Road, 4th Floor
Current Mailing Address
Glen Allen VA
City State
Telephone [phone]
10900 Nuckols Road, 4th Floor
Current Street Address
23060 Glen Allen
Zip City
Fax Number N/A
VA 23060
State Zip

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
NIA
Name of Registered Agent
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
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 Fields
Type or print name
Signature
Manager, Electric Transmission Services .:..,;;:....
Title or Authority Authorized Kepresentat] e
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Date
�intli`� peV+v�tui �ovC , a Notary Public of the County of 4ekV1co
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State of NtwV-Ga;o4[na, hereby certify that KeokA 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 Z day of /74u y 20 Z L
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