NCC230296_FRO Submitted_20230202

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name UPS Facility GME - Pipeline
2. Location of land -disturbing activity: County Alamance City or Township Haw River
Sen. Ralph Scott Pkwy 36.058227°-79.331529'
Highway/Street Latltude(decimal degrees) Longitude (decimal degrees)
3. Approximate date land -disturbing activity will commence: Fall/Winter 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): 5.8
6. Amount of fee enclosed: $ 600 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robert Lepsic
Phone: Office # 919-810-7883
E-mail Address [e-mail]
Mobile # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT R/W
Name
Current Mailing Address
City
Phone: Office #
Current Street Address
State Zip City
State
Mobile #
Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Public Service Company of North Carolina, Inc. [e-mail]
Company Name
P.O. Box 1398
Current Mailing Address
Gastonia, NC 28053
E-mail Address
800 Gaston Road, Building A
Current Street Address
Gastonia, NC 28056
City State Zip City State Zip
Phone: Office # 704-810-3259 Mobile # N/A
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
CT Corporation System (NCSOS ID#519077)
Name of Registered Agent
160 Mine Lake Ct, Ste 200
Current Mailing Address
Raleigh, NC 27615
City State Zip
CT-StateCommunicationsoo wolterskluwer.com
E-mail Address
160 Mine Lake Ct, Ste 200
Current Street Address
Raleigh, NC 27615
City
State Zip
Phone: Office # 302-777-0204 Mobile # N/A
Sherry McGinnes
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
N/A
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Andrew Moore
Typq or print name
—6LZ
Signature
Director - Engineering & Construction
Title or Authority
9L/12 -
Date
----------
I. a n
a Notary Public of the County of to ac'+p n
State of North Carolina, hereby certify that And IIv 160 Le appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 8 day of N dVt 20 22
F
YNTHIA M. ALVARADONOTARY PUBLIC Not Gaston County
North CarolinaMy commission ex ires ��yommission Expires 10' l- 25 p � w ZS

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
N/A
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
N/A
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
N/A
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A
Company 2 Name E-mail Address
Current Mailing Address
City State
Phone: Office #
N/A
Company 3 Name
Current Mailing Address
City State
Phone: Office #
N/A
Company 4 Name
Current Mailing Address
City State
Phone: Office #
N/A
Company 5 Name
Current Mailing Address
City State
Phone: Office #
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Street Address
Zip City State
Mobile #
E-mail Address
Zip
Current Street Address
Zip City State Zip
Mobile #