NCC242530_FRO Submitted_20240823

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: Structure 570/250 Repair
*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 N/A N/A
2. Location of land-disturbing activity: County: Halifax City or Township: Littleton
Highway/Street: HWY 158 Latitude: 36.456049 Longitude:-77.838682
3. Approximate date land-disturbing activity will commence: 7/2/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.61
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: Charles J. Schleicher E-mail Address:
[e-mail]
Phone: [phone] Mobile: [phone]
9. Landowner(s)of Record:
Landowner(s) of Record
Name Email Business Phone Mobile Phone
Mary A Smith
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
HWY 158 Littleton North 27850 108 Elams Road Littleton North 27850
Carolina Carolina
Name Email Business Phone Mobile Phone
Roseburg Resource Company
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
Summit Rd Littleton North 27850 3660 Gateway Springfield Oregon 97477
Carolina Street

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
Dominion Energy Services, Inc. [e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
120 Tredegar Richmond VA 23219 120 Tredegar Richmond VA 23219
Street Street
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 System ct- 8887249870
[e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
160 Mine Raleigh NC 27615 160 Mine Lake Raleigh NC 27615
Lake Ct, Ste Ct, 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
CT Corporation System [e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
160 Mine Raleigh North 27615 160 Mine Lake Raleigh North 27615
Lake Ct Carolina Ct Carolina
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
C2 Environmental [e-mail] 757-223-0071
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
11846 Rock Newport VA 23606 11846 Rock Newport VA 23606
Landing Dr A Landing Dr A

Additional Details
1. Stream Classification: WS-IV: Water Supply IV
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.