NCC223780_FRO Submitted_20221114

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 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. PNG Line 477 (Line 10 Replacement) Laydown Yard
1. Project Name
2. Location of land -disturbing activity: County Stanly
City or Township Tyson
Highway/Street Old Aquadale Rd & Bethlehem Church Rd Latitude 35014'15.43"N Longitude 80014'27.68"W
3. Approximate date land -disturbing activity will commence: February 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Laydown Yard
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 28.1
6. Amount of fee enclosed: $ 2,900 . 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 No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name AARON WELDON E-mail Address [e-mail]
Telephone [phone] cell # N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Aquadale Properties LLC Tim Agner (704)-906-6037 N/A
Name Telephone Fax Number
PO BOX 1037 12423 OLD AQUADALE RD
Current Mailing Address Current Street Address
SALISBURY NC 28145-1037 Norwood NC 28128
City State Zip City State Zip
1020 & 1327 16.19'21 (1327) & 706 (1020)
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.
Duke Energy (Piedmont Natural Gas) [e-mail]
Name E-mail Address
4720 Piedmont Row Drive 4720 Piedmont Row Drive
Current Mailing Address Current Street Address
Charlotte, NC 28210 Charlotte, NC 28210
City
State
Telephone [phone]
Zip City State Zip
Fax Number N/A

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:
N/A
N/A
Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State Zip
City State Zip
Telephone N/A
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:
N/A
N/A
Name of Registered Agent
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State Zip
City State Zip
Telephone N/A
Fax Number N/A
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). 1 agree to provide
corrected information should there be any change in the information provided herein.
AARON WELDON
Ty ri name
Signature
Senior Project Manager
Title o Authority
J 2D 2
Date(
I, b I P� lC 9A (37 J �-� e // a Notary Public of the County of M i-gu 17 5
State of North Carolina, hereby certify that 1?q-7Z-v N 0-)!2_ L--,J 0 /0 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 ly of 1'v7 47 , 20 2- 2--
�. Notary
My commission expires
.,
A r
r