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HomeMy WebLinkAboutNCC220642_FRO Submitted_20220204FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION 11192021 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 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 and/or fax information unavailable, place N/A in the blank.) Part A. Hwy 401 Assemblage 401 GME 1. Project Name 2. Location of land -disturbing activity: County Wake City or Township Garner Highway/Street Hwy 401 Latitude 35.6688120 Longitude-78.6952120 3. Approximate date land -disturbing activity will commence: December 2021-January 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Installation 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.0 Express:$1250 Standard: $ 500 6. Amount of fee enclosed: _$Total:$1750 The Express Permitting application fee is a dual charge. The normal fee of $100.00 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 $2,900). NOTE: Both fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes No Enclosedx 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Andrew Moore E-mail Address andrew.moore@dominionenergy.com Telephone 704-810-3259 Cell # N/A Fax # N/A 9. Landowner(s) of Record (attach accompanied page to list additional owners): NCDOT Right -of -Way N/A N/A Name Telephone Fax Number N/A N/A Current Mailing Address Current Street Address N/A N/A City State Zip City State Zip 10, Deed Book No. N/A Page No. N/A Provide a copy of the most current deed. Part B. 1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship, the name of the owner or manager may be listed as the financially responsible party. PUBLIC SERVICE COMPANY OF NORTH CAROLINA, INCORPORATED andrew.moore@dominionenergy.com 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 Telephone 704-810-3259 Fax Number 803-217-7810 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 E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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 (NCSOS ID #519077) Attn: Andrew Moore (Project ID #0070179) andrew.moore@dominionenergy.com 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 Telephone 704-810-3259 Fax Number 803-217-7810 (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: Kleinfelder klane@kleinfelder.com Engineering Firm or other consultant E-mail Address Keely Lane 910-233-8858 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. Andrew Moore Type print name Signature Director — Engineering & Construction Title or Authority _ I A b12-ji22 Date a Notary Public of the County of -GLa Y-) State of North Carolina, hereby certify that tjndYew M('tyL appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this J0 day of 20 2 2 CYNTHIA M. ALVARADO Notallry Se I NOTARY PUBLIC �` Gaston County My commission expires_0L Ub2Y - , 1702fj North Carolina My Commission Expires A 0 ,' 2