HomeMy WebLinkAboutNCC230672_FRO Submitted_20230403FINANCIAL 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
2.
3.
4.
5.
Project Name PNG Line 479 Staging Yard
Location of land -disturbing activity: County Robeson City or Township Lumberton
Singletary Church Rd 34.60092-78.86909
Highway/Street LatltUde(decimal degrees} LOngltude(decimal degrees)
Approximate date land -disturbing activity will commence: Spring 2023
Purpose of development (residential, commercial, industrial, institutional, etc.). Utility Installation
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 30
6. Amount of fee enclosed: $ 3,000 . 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 ❑ Enclosed px No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Shaun Huneycutt E-mail Address Shaun.Huneycutt@duke-energy.com
Phone: Office # N/A
Mobile # 704-438-0036
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Piedmont Natural Gas Co Inc N/A N/A
Name
PO Box 33068
Current Mailing Address
Charlotte, NC 28233
City
State Zip
Phone: Office # Mobile #
3012 Singletary Church Rd
Current Street Address
Lumberton, NC 28358
City
State
Zip
10. Deed Book No. 1783 Page No. 110 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.
Company Name
4720 Piedmont Row Drive
Current Mailing Address
Charlotte, NC 28210
City State Zip
Phone: Office # 704-731-4245
Tom. Morris2@Duke-Energy.com
E-mail Address
4720 Piedmont Row Drive
Current Street Address
Charlotte, INC 28210
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:
C T Corporation System CT-STATECOMMUNICATIONS@WOLTERSKLUWER.COM
Name of Registered Agent E-mail Address
160 Mine Lake Court Suite 200 160 Mine Lake Court Suite 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office # 844-252-0698 Mobile # N/A
Karen Rozer
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)
Continued from Items 9 & 10 in Part A of the Financial ResponsibilitytOwnership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
N/A
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 3 of Record:
NIA
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:
NIA
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:
NIA
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 9 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.
N/A
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
N/A
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
N/A
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
NIA
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
(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.
NIA
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.
Tom Morris
Type or print name
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Signature
Senior Project Manager
Title or Authority
11-7 /Z6zz
Date
a Notary Public of the County of _ /oPe111G1.
State of North Carolina, hereby certify that 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 % Iyday ofz&--' , 20 4
JAN PET CURETON r
No ry
NOTARY PUBLIC
Mecklenburg County My commission expires % ��2
State of North Carolina