NCC223100_FRO Submitted_20220907

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 N/A in the blank.)
Part A.
1. Project Name NC-98 Enhancements
2. Location of land -disturbing activity: County Durham City or Township Durham
Leesville Rd 35.9354-78.811931
Highway/Street LatltUde(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Laydown Yard
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.0
Standard: $300
Express:$750
6. Amount of fee enclosed Total: $1050 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 peracre up to eight acres, afterwhich 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andrew Moore
Phone: Office # 704-810-3259
E-mail Address [e-mail]
Mobile # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
JTT Properties N/A
Name
6109 Turnipseed Rd
Current Mailing Address
Phone: Office #
6109 Turnipseed Rd
Current Street Address
Wendell, NC 27591 Wendell; NC 27591_
City
10. Deed Book
::i
State Zip City
Page No. 826
State
N/A
Mobile #
Zip
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).
Public Service Company of North Carolina, Inc.
Company Name
P.D. Box 1398
Current Mailing Address
Gastonia, NC 28053
City State Zip
Phone: Office # 704-810-3259
[e-mail]
E-mail Address
800 Gaston Road, Building A
Current Street Address
Gastonia, NC 28056
City State Zip
Mobile# N/A
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:
CT Corporation System (NCSOS ID#519077) [e-mail]
Name of Registered Agent
160 Mine Lake Ct, Ste 200
Current Mailing Address
Raleigh, NC 27615
E-mail Address
160 Mine Lake Ct, Ste 200
Current Street Address
Raleigh, NC 27615
City State Zip City
Phone: Office # 704-810-3259
Andrew Moore
Mobile # N/A
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
N/A
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.
N/A
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:
Kleinfelder, Inc.
Engineering firm or other consultant
Keely Lane
Individual contact person (type or print)
[e-mail]
E-mail Address
910.233.8858 N/A
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.
Andrew Moore
Typ,P,7or print name
(�'j
Signature
Director - Engineering & Construction
Title or Authority
5h-0 /2-62-2—
Date
1, i 'ti�4d 10 , a Notary Public of the County of �C S
State of North Carolina, hereby certify that mac. re w__ I Y n c, 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 20day of , 20 22
CYNTHIA M. ALVARADO
NOTARY PUBLIC Wy
Gaston County �1� �
al North Carolina My commission expires (YII I -4. 2b2s
iMy Commission Expires i 0-7- S