NCC222897_FRO Submitted_20220812

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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. Dominion Energy Line T-77 La down Yard
1. Project Name gY Lay
down
Location of land -disturbing activity: County Person City or Township ROugemont
Highway/Street Fitch Oakley Road SR 1727 Latitude 36.304675 Longitude-78.809286
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utl Ilty
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.47
6. Amount of fee enclosed: $ 500 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Bob Lepsic E-mail Address [e-mail]
Telephone cell # 919-810-7883 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Forest L. and Sondra H Oakley
Name Telephone Fax Number
376 Fitch Oakley Rd Same as Mailing Address
Current Mailing Address Current Street Address
Rougemont, NC 27565 Same as Mailing Address
City State Zip City State Zip
10. Deed Book No. 1050,137, and 17 Page No. 750,519, and 629 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 maybe listed as the financially responsible party.
Public Service Company of NC, Inc. [e-mail]
Name E-mail Address
PO Box 1398 800 Gaston Road, Building A
Current Mailing Address
Gastonia, NC 28053
City State
Telephone [phone]
Current Street Address
Gastonia, NC 28053
Zip City
State
Fax Number803-217-7810
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:
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:
CTC°rporalion System(NCSOS90519077) Attn: Andrew Mo (ProjeO ID 0071615) and rew. moore0domi nionenergy.com
Name of Registered Agent E-mail Address
160 Mine Lake Court Ste. 200
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip
Telephone [phone]
City State Zip
Fax Number 503-217-7810
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 P.E.
Type print name
Signature
Director - Engineering & Construction
Title or Authority
Date
I, eix o , a Notary Public of the County of L..'­Qs n
State of North Carolina, hereby certify that _ dre,w Iy ll_;o « 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 t day of 20 ZZ —
CYNTHIA M. ALVARAUO Not
S I NOTARY PUBLIC
Gaston County
North Carolina My commission expires; �% �s
My Commission Expires 0' 2