NCC241806_FRO Submitted_20240625

Check if this project is ARPA-funded ❑
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.
1. Project Name Colonial Response
*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).
N/A
2. Location of land-disturbing activity: County Mecklenburg City or Township Huntersville
Highway/Street Huntersville-Concord Rd Latitude(decimal degrees)35.4129 Longitude(decimal degrees)780.8058
3. Approximate date land-disturbing activity will commence: June 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Cleanup Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.92
6. Amount of fee enclosed: $ 200 (Previous $600). 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 e No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chip Little E-mail Address clittle( colpipe.com
Phone: Office# 678.762.2333 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Colonial Pipeline Company _678.762.2333 678.644.0565
Name Phone: Office# Mobile#
P.O. Box 1624 1000 Lake Street
Current Mailing Address Current Street Address
Alpharetta, GA 30009-9934 Alphretta, GA 30009
City State Zip City State Zip
10. Deed Book No.37680/35350 Page No.544/546 Provide a copy of the most current deed.
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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).
Colonial Pipeline Company clittlet�colpipe.com
Company Name E-mail Address
P.O. Box 1624 1000 Lake Street
Current Mailing Address Current Street Address
Alpharetta, GA 30009-9934 Alpharetta, GA 30009
City State Zip City State Zip
Phone: Office# 678.644.0565 Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners 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:
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)
(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:
Corporation Service Company SOP( cscglobal.com
Name of Registered Agent E-mail Address
2626 Glenwood Ave. Ste. 550 _ 2626 Glenwood Ave. Ste. 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Phone: Office# 888.690.2882 Mobile#
Litigation Services
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.
Michael D. Smith V-P Environmental, Health, Safety & Compliance
Type or print name Title or Authority
Signature Date
I, E . 5LLi'4Xtfl , a Notary Public of the County of re,i1Steln
State of • hereby certify that m L A, D SY1N-4.4'" 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 kLi day of ( , 20 oZ�-•�'
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(AQI- AIk-
Notary
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My commission expires lit 1, k1
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