NCC224178_FRO Submitted_20221228

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.
Project Name_ Dominion Energy Services, Inc. on behalf of Atlantic Coast Pipeline LLC
Location of land -disturbing activity: County_ Sampson, Hartnett, Cumberland, and Robeson
City or Township N/A
Highway/Street Latitude_350 17' 52.922"N (AP-2) Long itude_78°31'28.593" W
Approximate date land -disturbing activity will commence: January 2023
Purpose of development (residential, commercial, industrial, institutional, etc.):_Industrial
Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ 1,018 (original) + 10
(Mod #1) + 21 (increase Mod #2) —1 (decrease Mod #3) +0 (Mod #4) = 1,048 total acreage. As part of
this modification (Mod #5), 0.5 acre of workspace identified in Mod #5 as requiring restoration, no longer
requires restoration and is being changed to undisturbed and 6.6 acres of previously permitted
workspace identified as undisturbed in Mod #5 will be impacted during restoration activities. New totals
include: Previously permitted — 1,048 acres; Undisturbed — 478.3 acres; Undisturbed -landowner
felled — 9.8 acres (included in the 478.3 acres). No new workspace outside the previously
permitted project is proposed.
Station
Acres
Workspace Type
Workspace Changed to Undisturbed
7088+00
0.1
Right -of -Way
8970+00
0.4
Access Road
Total
0.5
Workspace Changed to Restoration
7006+00
2.4
Access Road
7208+00
1.8
Access Road
8682+00
0.2
Right -of -Way
9161+00
0.1
Right -of -Way
9380+00
0.8
Right -of -Way
9418+00
0.3
Right -of -Way
9264+00
1.0
Right -of -Way
Total
6.6
6. Amount of fee enclosed: (1,018 acres/$66,170.00 Original amount) + (10 acres/$650.00 Mod#1 amount
(Feb. 2018)) + (21 acres/$1,365.00 Additional) — (1 acre/$0) + (1 acre/$100 additional) = Total Acreage
1,048 acres/$68,185.00 (fee previously paid). No new workspace is proposed; therefore, no application
fee is required.
i. Has an erosion and sediment control plan been filed? Yes ® Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andrew Dorman E-mail Address andrew.dorman(a-dominioneneroy.com
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
City
Current Street Address
State Zip City
10. Deed Book No. N/A Page No.
current deed.
Part B.
State
Provide a copy of the most
Zip
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(cDdominionenergy.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: Lisa C. Messinger, Manager Environmental Regulations
120 Tredegar Street
Richmond, VA 23219
lisa.c.messinger(c-)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, NC 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
corrected information should there be any change in the information provided herein.
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I, C h �'�S-In "(.��i Joy- _,a Notary Public of the C- q of
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State of - GaFel hereby certify that Q-1 )arr In H-r-M,; Alec_ 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 a a rilay of IJO'Qfvn ber , 20 ,,4 J-
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