NCC230609_FRO Submitted_20230327

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 US 74 Bridge Attachment Replacement
2. Location of land -disturbing activity: County Rutherford City or Township Forest City
US 74. us 221A, MD Blanton Rd, wells Dr. 35.314966-81.860350
Highway/Street LatltUde(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: March 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility - Linear
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.65
6. Amount of fee enclosed: $ 600.00 The application fee of $100.00 per acre (rounded
up to.the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bobby Ley, PE E-mail Address [e-mail]
Phone: Office # NSA Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Alexander United Methodist Church
Name
288 Brookmount Ave.
Current Mailing Address
Forest City, NC 28043
City
10. Deed Book No. 979
State Zip
Phone: Office # Mobile #
Current Street Address
City State Zip
Page No. 166 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, Incorporated
Company Name
800 Gaston Road
Current Mailing Address
Gastonia, NC 28056
City State Zip
Phone: Office #
[e-mail]
E-mail Address
800 Gaston Road, Building A
Current Street Address
Gastonia, NC 28056-9486
City State Zip
Mobile # [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:
CT Corporation System (NCSOS#0519077)
Name of Registered Agent
160 Mine Lake Court Suite 200
Current Mailing Address
Raleigh NC 27615
[e-mail]
E-mail Address
160 Mike Lake Ct. Suite 200
Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
Phone: Office # 302-777-0204 Mobile # N/A
Attn: Sherry McGinnes (Project ID# P70405)
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:
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
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, PE
Type r print ame
. ��L
Signature
Director - Engineering & Construction
Title or Authori
z � 0 20 -s
Date
I, WI yflyt I tk 1 A - AvayaJo , a Notary Public of the County of rTach n
State of North Carolina, hereby certify that _AY)Ayc 1A) Moof 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 ( Q+iA day of 202-3
CYNTHIA M. ALVARADO
NOTARY PUBLIC NotYry
Gaston County
North Carolina OchL _ ,' .� Zo 2�
My Commission Expires t6 -?- tS Imy commission expires f�R.►' '

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Melvin Capital Investments, LLC
Name Phone: Office # Mobile #
216 Newberg Rd.
Current Mailing Address Current Street Address
Chapin, SC 29306
City State Zip City State Zip
Deed Book No. 2048 Page No. 3838 Provide a copy of the most current deed.
Landowner 3 of Record:
South Broadway Corporation
Name Phone: Office# Mobile #
PO Box 944
Current Mailing Address Current Street Address
Rutherfordton, NC 28139
City State Zip City State Zip
Deed Book No. 342 Page No. 556 Provide a copy of the most current deed.
Landowner 4 of Record:
J. David Walsh & Talmadge Tumer, Co -Trustees of the Jack Woddord Revocable Trust
Name Phone: Office # Mobile #
PO Box 1096
Current Mailing Address Current Street Address
Boiling Springs, NC 28017
City State Zip City State Zip
Deed Book No. 1 169 Page No. 573 Provide a copy of the most current deed.
Landowner 5 of Record:
Barry R. Sullens
Name Phone: Office # Mobile #
168 Frontage Rd.
Current Mailing Address Current Street Address
Forest City, NC 28043
City State Zip City State Zip
Deed Book No. 2030 Page No. 2213 Provide a copy of the most current deed.