NCC232143_FRO Submitted_20230718

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 P73160- Fair Haven Rest Home Gas Main Extension
2. Location of land-disturbing activity: County Rutherford City or Township Forest City
Bethany Church Road 35°18'1.4"N 81°54'3.2"W
Highway/Street Latitude(decimal degrees) 35.3004° Longitude(decimal degrees) -81.9009°
3. Approximate date land-disturbing activity will commence:August 1,2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Linear
5. Total acreage disturbed or uncover.odi including off-site borrow and waste areas): 4.1 Acres
Express: $125u
Regular: $500
6. Amount of fee enclosed Total: $ 1750 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes x❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Bob Lepsic, PWS E-mail Address [e-mail]
Phone: Office# N/A Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
NCDOT Highway Division 13, District 1 N/A N/A
Name Phone: Office# Mobile#
3931 NC 226 South N/A
Current Mailing Address Current Street Address
Marion NC 28752 N/A
City State Zip City State Zip
10. Deed Book No. NCDOT ROW Page No. NCDOT ROW 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, Incorporated [e-mail]
Company Name E-mail Address
800 Gaston Road 800 Gaston Road, Building A
Current Mailing Address Current Street Address
Gastonia NC 28056 Gastonia NC 28056-9486
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#0519077)
Attn:Sherry McGinnes(Project ID#P73160) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip 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 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
Phone: Office# N/A Mobile# N/A
N/A
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.
Dominion Energy North Carolina
Company DBA Name
(d) If 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:
S&ME, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Matthew H.Kunkle, P.E. 704-523-4726 803-924-5523
Individual contact person (type or print) Phone: Office# Mobile#
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,P.E. Director- Engineering&Construction
Type r print name Title or A thor'ty
(p 1402 3
Signature Date
I,ey-\-V1'1CL. 4. rC1 ia,r(L O , a Notary Public of the County of &GIS tbY\
State of North Carolina, hereby certify that l 1 Ylrri rev,' (( I _ 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 e- day of 3 u , 20 23
CYNTHIA M. ALVARADO A
NOTARY PUBLIC Not.
Gaston County
North Carolina
S-My Commission Expires 10-1-2< My commission expires I 0 ( ED

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:
Fair Haven Properties LLC N/A N/A
Name Phone: Office# Mobile#
149 Fair Haven Drive 830 Bethany Church Road
Current Mailing Address Current Street Address
Bostic NC 28018 Forest City NC 28043
City State Zip City State Zip
Deed Book No.2039 Page No. 1197 Provide a copy of the most current deed.
Landowner 3 of Record:
Anthony Kevin Hamrick N/A N/A
Name Phone: Office# Mobile#
929 Bethany Church Road 929 Bethany Church Road
Current Mailing Address Current Street Address
Forest City NC 28043 Forest City NC 28043
City State Zip City State Zip
Deed Book No. 1076 Page No. 122 Provide a copy of the most current deed.
Landowner 4 of Record:
Anthony Kevin Hamrick N/A N/A
Name Phone: Office# Mobile#
929 Bethany Church Road 927 Bethany Church Road
Current Mailing Address Current Street Address
Forest City NC 28043 Forest City NC 28043
City State Zip City State Zip
Deed Book No.838 Page No.210 Provide a copy of the most current deed.
Landowner 5 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No.N/A Page No. N/A Provide a copy of the most current deed.