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HomeMy WebLinkAboutNCC216870_FRO Submitted_20211213FINANCIAL RESPONSIBILITYIOWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION 08012007 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 Environment and Natural Resources. (Please type or print and, if the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.) Part A. PNG McLeansville Publix Extension 1. Project Name 2. Location of land -disturbing activity: County Guilford City or Township McLeansville Highway/Street Birch Creek Road Latitude 36005'05"N Longitude 79039'36"W 1 Approximate date land -disturbing activity will commence: Fall 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Energy 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.5 AC $1,890[6 ac x $65 6. Amount of fee enclosed: $ * 6 AC 9250a . The Express Permitting application fee is a dual charge. The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are rounded up to the next whole acre and need to be paid by separate checks to NCDENR. 7. Has an erosion and sediment control plan been filed? Yes No Enclosed X 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Jimmy Brown E-mail Address Jimmy.Brown5@duke-energy.com Telephone (336) 215 8769 Cell # Fax # 9_ Landowner(s) of Record (attach accompanied page to list additional owners): Public RIW - NCDCT Name Telephone Fax Number Current Mailing Address Current Street Address City State Zip City State Zip 10. Deed Book No. Page No. Provide a copy of the most current deed. Part B. 1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties an an attached sheet): Piedmont Natural Gas Company, Inc. Jimmy.Brown5@duke-energy.com Name E-mail Address PO Box 33068 4729 Piedmont Row Drive Current Mailing Address Current Street Address Charlotte NC 28233 Charlotte NC 28210 City State Zip City State Zip Telephone (336) 215-8769 Fax Number 2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated North Carolina Agent: Name Current Mailing Address City Telephone. E-mail Address Current Street Address State Zip City State Zip Fax Number (b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation, give name and street address of the Registered Agent: CT Corporation System Name of Registered Agent 160 Mine Lake Court, Ste 200 Current Mailing Address Raleigh NC 27615 City State Zip Telephone 855.316.8944 �II1 E-mail Address same Current Street Address City State Zip Fax Number (c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other consultant who can assist in providing any necessary information regarding the plan and its preparation: W.K. Dickson & Co., Inc. Engineering Firm or other consultant Matthew D. Bare mbare@wkdickson.com E-mail Address (704) 334-5348 Individual contact person (type or print) Telephone Fax Number 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 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 Person). I agree to provide corrected information should there be any change in the information provided herein. Kevin Sell Type or print name Signature Operations Manager Title or Authority 6 -23- zoz 1 Date Matthew D. Bare a Notary Public of the County of Mecklenburg State of North Carolina, hereby certify that Kevin Sell appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. ✓k Witness�\4no aj�ptarial seal, this _day of 2031/ _ �Ci AR Y Notary — Seal z — p U �G My commission expires L L wZZ NBUR�