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Home My WebLink AboutNCC240646_FRO Submitted_20240307 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 NCGO1 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. 1. Project Name: Four Oaks Phase B *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). Is Project ARPA Funded ARPA Project Name ARPA Project# No 2. Location of land-disturbing activity: County: Johnston City or Township: Four Oaks Highway/Street: NCDOT R/W Latitude: 35.463800 Longitude:-78.388800 3. Approximate date land-disturbing activity will commence: 3/4/2024 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Other: Utility 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.30 6. 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). 7. Has an erosion and sediment control plan been filed? No 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name: Joshua Lanaville E-mail Address: Joshua.Lanaville@duke-energy.com Phone: 919-705-5061 Mobile: 919-223-4279 9. Landowner(s)of Record: Landowner(s) of Record Name Email Business Phone Mobile Phone Jones Creek, LLC Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip Thunder Road Four Oaks NC 27524 5160 NC Garner NC 27529- HIGHWAY 42 W 8417 Name Email Business Phone Mobile Phone Angel Garcia Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 4386 G US HWY FOUR NC 27524- 4386 US FOUR NC 27524- 301 OAKS, 9252 HIGHWAY 301 S OAKS, 9252 #G Name Email Business Phone Mobile Phone ELIJAH J & LEEANN R HIGGINS Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 4386 US FOUR OAKS NC 27524 4386 US FOUR OAKS NC 27524 HIGHWAY 301 S HIGHWAY 301 S Name Email Business Phone Mobile Phone _ SHANNON ENNIS Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 4386 C US HWY FOUR OAKS NC 27524 4386 C US HWY FOUR OAKS NC 27524 301 S 301 S Name Email Business Phone Mobile Phone NCDOT, Dist 3, Div 4 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 67 Jr Rd Suite 700 Selma NC 27576 67 Jr Rd Suite 700 Selma NC 27576 Name Email Business Phone Mobile Phone _ Grace Puckett Physical Address Mailing Address Street 1 City State _ Zip Street 1 City State Zip 4386 J US HWY FOUR OAKS NC 27524 2230 E DOLPHIN OAK ISLAND NC 28465- 301 DR 6109 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). Primary Financially Responsible Party Company Name Email Business Phone Mobile Phone Piedmont Natural Gas Joshua.Lanaville@duke- energy.com Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 250 Five Points Dudley NC 28333 250 Five Points Dudley NC 28333 Rd. Rd. Additional Financially Responsible Parties 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: Registered Agent Information Name Email Business Phone Mobile Phone CT Corporation ct- 919-844-8360 statecommunications@wolterskluwer.com Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 160 Mine Raleigh NC 27615 160 Mine Lake Ct Raleigh NC 27615 Lake Ct Ste Ste 200 200 (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: North Carolina Agent Information Name Email Business Phone Mobile Phone Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip Engineering/Consulting Firm Information Name Email Business Phone Mobile Phone TRC Companies mayoung@trccompanies.com 3463552016 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 4612 Sweet Knightdale NC 27545 4612 Sweet Knightdale NC 27545 Melody Ln Melody Ln Additional Details 1. Stream Classification: NSW: Nutrient Sensitive Waters 2. Was Express Review Requested: Yes 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.