NCC222026_FRO Submitted_20220531

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. Line 11 Replacement Project
1. Project Name p 1
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street Lake Valley Drive Latitude 35.0800° N Longitude 78.9671 ° W
3. Approximate date land -disturbing activity will commence:April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Energy
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20.13
6. Amount of fee enclosed: $41100 . 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Charlie Gilman E-mail Address [e-mail]
Telephone N/A Cell # [phone] Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Private Easement, Public NCDOT RA/V, & Noted on Plans
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. 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.
Piedmont Natural Gas Company, Inc.
Name
4720 Piedmont Row Drive
Current Mailing Address
[e-mail]
E-mail Address
4720 Piedmont Row Drive
Current Street Address
Charlotte NC 28210 Charlotte NC 28210
City
State Zip City
Telephone [phone] Fax Number NIA
State
Zip

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:
NIA NIA
Name E-mail Address
NIA NIA
Current Mailing Address
NIA
City State Zip
Telephone NIA
Current Street Address
NIA
City State Zip
Fax Number N/A
(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:
Karen Rozar (CT Corporation) [e-mail]
Name of Registered Agent
160 Mine Lake Court, Suite 200
Current Mailing Address
Raleigh NC 27615
City State Zip
E-mail Address
NIA
Current Street Address
NIA
City
Telephone [phone] Fax Number NIA
State Zip
(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. [e-mail]
Engineering Firm or other consultant E-mail Address
Logan Tripp [phone] NIA
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.
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Project Manager
Title or Authority
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Date
t, n - Sri0k) , a Notary Public of the County of 6,12�12!210-
State of North Carolina, hereby certify that S11 _ appeared personally
before me this and being duly swom acknowledged that the above form was executed by him.
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Witn` �i r>s, ial seal, this yday of 20_,3D
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Notary
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