NCC231240_FRO Submitted_20230502

Check if this project is ARPA-funded 0
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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.
P73842-South Main Street(US 29)Gas Main Improvement
1. Project Name
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure(DWI).
WA
Rowan China Grove
2. Location of land-disturbing activity: County City or Township
South Main Street(US 29) 35'35'25.6'N 80.33'06.4"W
Highway/Street Latitude(decir.i )35.590° Longitudetdecirnaidegreesi,eo_552°
May 15,2023
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.):utility-Linear
15.9 Ac.
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):
6. Amount of fee enclosed: $ 1600 . 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 El Enclosed t1 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Bob S.Lepsic,PWS robert.lepsicdominionenergy.com
Name E-mail Address
N/A 919-810-7883
Phone: Office# Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
NCDOT-DIVISION 9,DISTRICT 1
Name Phone: Office# Mobile#
4770 South Main Street NCDOT Maintained RAN
Current Mailing Address Current Street Address
Salisbury NC 28147-9386
City State Zip City State Zip
10. Deed Book No. Page No. 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 [e-mail]
Company Name E-mail Address
P.O.Box 1398 800 Gaston Road,Building A
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28056-9486
City State Zip City State Zip
Phone: Office# 70`�$10 3sz9 Mobile# loa 718 a11a
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#0519077) [e-mail]
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 Raleigh NC 27615
City State Zip City State Zip
Phone: Office# 302 777 o2aa Mobile#
Attn:Sherry McGinnes(Project ID#P73842)
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:
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.
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,P.E. Director-Engineering&Construction
Type or print name Title.or Authority
y 1 4 .3/V /1°
Signature Date
M.. Mvarar v , a Notary Public of the County of l7 (,Z'
State of North Carolina, hereby certify that Ar1CreAkJ MOON), 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 /-•day of NA aX , 20 T3
CYNTHIA M. ALVARADO LI
•
NOTARY PUBLIC No ry
S e Gaston County �r
North Carolina My commission expires ber l26 26
My Commission Expiresr b-1- Z„