NCC230818_FRO Submitted_20230327

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
2
Project NameM-73 Cardinal to NC State Pipeline Project
Location of land -disturbing activity: County V V ake
City or Township Raleig h
Lake Wheeler Drive 35.64696-78.72272
Highway/Street Latltude(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: March 311 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Improvement
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 52.01 + 2.1 7
6. Amount of fee enclosed: $ 5,200 + 300 . 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Katy Mays, MP
Phone: Office # 803-563-4964
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Highway Division 5, District 1 919-733-3213
Name Phone: Office # Mobile #
1575 Mail Service Center
Current Mailing Address Current Street Address
Raleigh NC 27699-1575
City
10. Deed Book No.
State
NC DOT ROW
Zip City
Page No. N/A
State
Zip
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
Company Name
PO Box 1398
Current Mailing Address
Gastonia NC 28053
[e-mail]
E-mail Address
800 Gaston Road, Building A
Current Street Address
Gastonia NC 28056-9486
City State Zip City State Zip
Phone: Office # 704-718-4114 Mobile #
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# 051977)
Name of Registered Agent
160 Mine Lake Ct. Ste 200
Current Mailing Address
Raleigh NC 27615
City
State Zip
[e-mail]
E-mail Address
160 Mine Lake Ct. Ste 200
Current Street Address
Raleigh NC 27615
City
Phone: Office # 302-777-0204 Mobile #
Sherry McGinnes (Project ID # P73319)
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
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.
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 Director- Engineering and Construction
Type or prin nam Title or Authorit
2. %1 La2-023
Signature Date
I, bV�r n V tt Ol kk . A-wc y-OAC) a Notary Public of the County of (-,), Cg 1r1
State of North Carolina, hereby certify that Ay Ayf w WW,) (t, 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 ay of FtY 20 23
CYNTHIA M. ALVARADO No ry
SE 1 NOTARY PUBLIC
Gaston County O c L txr 4. 20 �J
North Carolina My commission expires U'U
My Commission Expires l0-'1— 25

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.
Landowner 2 of Record:
COTTON, RONNIE EVERETTE
336-340-2988
Name
Phone: Office # Mobile #
5 MANHATTAN DR.
0 LAKE WHEELER RD
Current Mailing Address
Current Street Address
BRICK, NJ 08723
Raleigh, NC 27603
City State Zip
City State Zip
14372
Deed Book No. Page No.1803
Provide a copy of the most current deed.
Landowner 3 of Record:
HENDRICKS, DONNA COTTON
919-605-7413
Name
Phone: Office # Mobile #
9200 LAKE WHEELER RD.
0 LAKE WHEELER RD
Current Mailing Address
Current Street Address
FUQUAY VARINA, NC 27526
Raleigh, NC 27603
City State Zip
City State Zip
14372
1077
Deed Book No. Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
TEN LAKES HOLDINGS LLC
919-795-4544
Name
Phone: Office # Mobile #
204 ROSSELLINI PL.
7600 TEN TEN RD
Current Mailing Address
Current Street Address
Cary, NC 27518
Raleigh, NC 27603
City State Zip
City State Zip
17993
0040
Deed Book No. Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
AREPS LLC
919-772-3673
Name
Phone: Office # Mobile #
7600 LAKE WHEELER RD.
7615 TEN TEN RD
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Raleigh, NC 27603
City State Zip
City State Zip
15080
1471
Deed Book No. Page No.
Provide a copy of the most current deed.

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.
Landowner 6 of Record:
LAKE WHEELER MOBILE ESTATES LLC 919-779-9797
Name Phone: Office # Mobile #
3305 DURHAM DR STE 109 1500 CHERRY LAUREL DR
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Raleigh, NC 27603
City State
Zip
City State Zip
10753
0543
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 7 of Record:
RALEIGH CITY OF
919-996-5575
Name
Phone: Office # Mobile #
PO BOX 590
6700 HICKORY DR
Current Mailing Address
Current Street Address
Raleigh, NC 27602
Raleigh, NC 27603
City State
Zip
City State Zip
13173
1065
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 8 of Record:
RALEIGH CITY OF
919-996-5575
Name
Phone: Office # Mobile #
PO BOX 590
6500 LAKE WHEELER RD
Current Mailing Address
Current Street Address
Raleigh, NC 27602
Raleigh, NC 27603
City State
Zip
City State Zip
03905
0795
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 9 of Record:
RALEIGH CITY OF
Name
PO BOX 590
Current Mailing Address
Raleigh, NC 27602
919-996-5575
Phone: Office #
0 LAKE WHEELER RD
Current Street Address
Raleigh, NC 27603
Mobile #
City State Zip City State Zip
01247
Deed Book No. Page No. 0507 Provide a copy of the most current deed.

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.
Landowner 10 of Record:
MAANI & PAARI LLC
201-748-9309
Name
Phone: Office # Mobile #
6307 LAKE WHEELER RD.
0 LAKE WHEELER RD
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Raleigh, NC 27603
City State Zip
City State Zip
1709
1888
Deed Book No. Page No.
Provide a copy of the most current deed.
Landowner 11 of Record:
MAAN I & PAARI LLC
201-748-9309
Name
Phone: Office # Mobile #
6307 LAKE WHEELER RD.
6305 LAKE WHEELER RD
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Raleigh, NC 27603
City State Zip
City State Zip
16690
1952
Deed Book No. Page No.
Provide a copy of the most current deed.
Landowner 12 of Record:
MAAN I & PAARI LLC
201-748-9309
Name
Phone: Office # Mobile #
6307 LAKE WHEELER RD.
6315 LAKE WHEELER RD
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Raleigh, NC 27603
City State Zip
City State Zip
16690
1952
Deed Book No. Page No.
Provide a copy of the most current deed.
Landowner 13 of Record:
HARRIS, STEPHEN BROOKS HARRIS, SWATI ASHAR
919-539-4211 (Swati Harris) 919-427-0164 (Stephen Harris)
Name
Phone: Office # Mobile #
12513 GARDEN TREE LN
1203 GRAEDON DR
Current Mailing Address
Current Street Address
Raleigh, NC 27614
Raleigh, NC 27603
City State Zip
City State Zip
16230
1416
Deed Book No. Page No.
Provide a copy of the most current deed.

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.
Landowner 14 of Record:
DOBRA, MATTHEW L FELDMAN-DOBRA, MELISSA L
Name
2432 SPINDLE CT
Current Mailing Address
Raleigh, NC 27603
City State
Deed Book No.18933
910-551-8805
Phone: Office # Mobile #
2432 SPINDLE CT
Current Street Address
Raleigh, NC 27603
Zip City
Page No. 2267
Landowner 15 of Record:
SCHMITT, MATTHEW DALE SCHMITT, KIMBERLEY ANNE
Name
2428 SPINDLE CT
Current Mailing Address
Raleigh, NC 27603
City State
Deed Book No. 19054
State
Zip
Provide a copy of the most current deed.
303-718-9099
Phone: Office # Mobile #
2428 SPINDLE CT
Current Street Address
Raleigh, NC 27603
Zip City State
0486
Zip
Page No. Provide a copy of the most current deed.
Landowner 16 of Record:
SHAMDASANI, RAJAN SHAMDASANI, SEEMA
Name
2424 SPINDLE CT
Current Mailing Address
Raleigh, NC 27603
Phone: Office #
2424 SPINDLE CT
Current Street Address
Raleigh, NC 27603
Mobile #
City State Zip City State Zip
Deed Book No.17944 Page No. 0538 Provide a copy of the most current deed.
Landowner 17 of Record:
STEELE, WILLIAM SCOTT STEELE, JENNIFER WOLFE
336-391-1429
Name Phone: Office # Mobile #
2420 SPINDLE CT 2420 SPINDLE CT
Current Mailing Address Current Street Address
Raleigh, NC 27603 Raleigh, NC 27603
City State Zip City State Zip
Deed Book No. 18815 Page No. 0381 Provide a copy of the most current deed.

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.
Landowner 18 of Record:
NORTH CAROLINA STATE OF 919-513-0470
Name
Phone: Office # Mobile #
116 W JONES ST.
3720 LAKE WHEELER RD
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Raleigh, NC 27603
City State
Zip
City State Zip
10780
Deed Book No.
Page No.1516
Provide a copy of the most current deed.
Landowner 19 of Record:
NORTH CAROLINA STATE OF
919-513-0470
Name
Phone: Office # Mobile #
116 W JONES ST.
3720 LAKE WHEELER RD
Current Mailing Address
Current Street Address
3720 LAKE WHEELER RD
Raleigh, NC 27603
City State
Zip
City State Zip
10780
1516
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 20 of Record:
JEFFREYS, JOSEPH RANDOLPH JR
919-833-9692
Name
Phone: Office # Mobile #
2703 TRYON RD
2703 TRYON RD
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Raleigh, NC 27603
City State
Zip
City State Zip
18289
0420
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 21 of Record:
UPCHURCH, GETTIS B
704-608-9297
Name
Phone: Office # Mobile #
8218 BAR HARBOR LN.
0 TRYON RD
Current Mailing Address
Current Street Address
Charlotte, NC 28210
Raleigh, NC 27603
City State
Zip
City State Zip
13328
2411
Deed Book No.
Page No.
Provide a copy of the most current deed.

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.
Landowner 22 of Record:
NORTH CAROLINA STATE OF
919-513-0472
Name
Phone: Office # Mobile #
116 W JONES ST.
1708 LAKE WHEELER RD
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Raleigh, NC 27603
City State
Zip
City State Zip
04812
0007
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 23 of Record:
BOARD OF TRUSTEES OF THE ENDOWNMENT FUND OF NC STATE UNNERSITY 919-513-0472
Name
Phone: Office # Mobile #
PO BOX 7001
0 CENTENNIAL PKWY
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Raleigh, NC 27603
City State
Zip
City State Zip
10522
0851
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 24 of Record:
NORTH CAROLINA STATE OF
919-513-0472
Name
Phone: Office # Mobile #
116 W JONES ST.
0 CENTENNIAL PKWY
Current Mailing Address
Current Street Address
Raleigh, NC 27603
Raleigh, NC 27603
City State
Zip
City State Zip
08430
1974
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 25 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
City State Zip City
State
W
Deed Book No. Page No. Provide a copy of the most current deed.