NCC233290_FRO Submitted_20231108

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 TL-81 Transmission Line Rebuild Phase 1 Carolina TL-239 Junction
2. Location of land-disturbing activity: County Halifax City or Township Roanoke Rapids
Linear ROW Start.36.4796 Start:-77.3473
Highway/Street Latitude(decimal degrees,Terminus 36.4583Longitude(declmal degrees) Terminus:-77 6385
3. Approximate date land-disturbing activity will commence: January 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial (Utility)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.60
6. Amount of fee enclosed $2,450 . 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❑ Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tom Miller E-mail Address [e-mail]
Phone: Office# 804.239.5646 Mobile# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
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
10. Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Various (See attached) - Legal rights of entry are secured for access to the ROW. The
project is within existing transmission line ROW managed and maintained by Dominion
Energy North Carolina (do Kevin Fields, PE, PMP)

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).
Dominion Energy North Carolina c/o Kevin Fields [e-mail]
Company Name E-mail Address
500 Dominion Blvd 500 Dominion Blvd
Current Mailing Address Current Street Address
Glen Allen, VA 23060 Glen Allen, VA 23060
City State Zip City State Zip
Phone: Office# 804.771 .3769 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 N/A
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 276515-6417 Raleigh, NC 276515-6417
City State Zip City State Zip
Phone: Office#888'724'9870 Mobile# N/A
Robert Ingato (Secretary)
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:
CT Corporation System N/A
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 276515-6417 Raleigh, NC 276515-6417
City State Zip City State Zip
Phone: Office# 888.724.9870 Mobile#
Robert Ingato (Secretary)
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
(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:
Dewberry Engineers Inc [e-mail]
Engineering firm or other consultant E-mail Address
Andrew Dahlman 804.767.4712 N/A
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.
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Ty e or print me Title or Authority
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Signature Date
I, I iQ f aLc Meac b , a Notary Public of the County of f}Lrl r...i c.o
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State of , hereby certify that M' 6.,c.Q-1 —6u-'4-^" A� 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( 1-t-t'day of*pfQM►a,2R , 20D 3
Laura Palge Meadows
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;.! Commonwealth of Virginia ary
Notary Public
Carrnbsia+No.7937194 f a�1 ++ O -
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MAP ID HALIFAX COUNTY LANDOWNER NAME MAP ID HALIFAX COUNTY LANDOWNER NAME MAP ID HALIFAX COUNTY LANDOWNER NAME
(AS SHOWN) PARCEL NUMBER (AS SHOWN) PARCEL NUMBER (AS SHOWN) PARCEL NUMBER
0_ 0
_ _ _ _ J
1 DOMINION 51 _ 0908774 PALMER,AUGUSTINA 101 0901117 JEAN,PAMELA E m H m
2 0900082 KAPSTONE KRAFT PAPER CORPORATION 52 0920172 PALMER,AUGUSTINA 102 0902023 BARRETT, RUSSELL I JR
ILI
3 _ 0917051 TOWN OF WELDON, 53 0907739 EMERY,ELDRIDGE L JR 103 0900407 BENNETT, DENNIS K Q H C.) Et
4 0920420 KAPSTONE KRAFT PAPER CORPORATION 54 _ 0907786 HARRIS,GREGORY T 104 0908798 MEHERRIN PROPERTIES LLC 2 Ct () co 0
5 0900205 KAPSTONE KRAFT PAPER CORPORATION 55 0904172 HALE,VIRGINIA EDWARDS 105 0902619 PUTNEY,VERGIE D z Z
6 0900084 KAPSTONE KRAFT PAPER CORPORATION 56 0919824 HALE,VIRGINIA EDWARDS 106 0908488 POWELL, BENJAMIN R&CONNIE W i N }
7 0900081 KAPSTONE KRAFT PAPER CORPORATION 57 0903937 MEDLIN,CARLA 107 0901976 HARRELL,WILLIE JAMES 0 cO H °6 Z
<8 _ 0900546 ROANOKE RAPIDS SANITARY DISTRICT, 58 0905914 MOORE, REBECCA D LIFE ESTATE 108 0907538 CARROLL,WILLIAM L JR 0 � 0
9 0909734 ROANOKE RAPIDS SANITARY DISTRICT, 59 _ 0910970 BARBER,JUSTIN 109 0907011 BURD,JOHN L a Q w 0
10 0920370 KAPSTONE KRAFT PAPER CORPORATION 60 0910969 HARRISON, BRANDON D 110 0907012 D&G RENTALS LLC J O Z X
11 0900083 KAPSTONE KRAFT PAPER CORPORATION 61 0905916 MOORE, REBECCAANN 111 0908127 GRIFFIN,AMY B H J Q
12 0909334 DOMINION-VIRGINIA POWER, 62 0904878 TILLERY,TAMMY L 112 0900384 BOISSEAU, PETER C JR Z Z Li-
1 3 0909341 CITY OF ROANOKE RAPIDS 63 0909095 JENKINS,BRENDA(LE) 113 0900049 STRICKLAND ASSOCIATES, di O J
14 _ 0900085 KAPSTONE KRAFT PAPER CORPORATION 64 0907105 BRANTLEY,JENNIFER RESTOM 114 0900383 KING, MARCUS D H H U 2
15 0900599 GURLEY,JOHN L 65 0903501 MCALLISTER,JOSEPH A&TAMMY L 115 0914037 STEPHENSON,GEORGE R SR HC
16 0909342 UNKNOWN, 66 0909015 WOLLETT, DEAN S 116 0908374 WARD,JAMES W w
17 0900390 NEW DIXIE REAL ESTATE LLC 67 0902100 JENKINS,JESSE F 117 0900050 STOREY, HENRY C CC Z
18 0901992 CARROLL, RACHEL REBECCA 68 0909113 SPEASE,TERRY L 118 0901525 STOREY, HENRY C 0 Lt
19 _ 0903131 BRADLEY,VERNON T JR LIVING TRUST 69 0900842 GARNER,SHERI JORDAN 119 0901348 WHITTON,SHELLY = H
20 0906588 PETERSON, ISAAC 70 _ 0909116 DE LA O, BENNY& 120 0900875 BABB,RICHARD M&LINDA
21 0901993 HARLOW,JAMES P 71 0920372 STATE OF NORTH CAROLINA 121 0913042 STRICKLAND ASSOCIATES BUILDERS, INC _
22 0908280 WALKER,JESSE JAMES 1/2 UNDV INT 72 0907104 CITY OF ROANOKE RAPIDS 122 0904108 HAWKINS, NANNIE MAE MRS.
U
23 0905632 CROWDER, DEBORAH B 73 0908954 WRIGHT,CHRISTOPHER M 123 0919669 STRICKLAND ASSOCIATES BUILDERS, INC. J Lu
24 0900513 HARLOW,JAMES P 74 _ 0907843 CLIPPARD,CHRISTOPHER CARLTON 124 0913043 STRICKLAND ASSOCIATES BUILDERS INC U a
25 0902888 BENNETT,DERRICK M 75 _ 0905283 HARRIS,ASHLEY TATE 125 0925242 STRICKLAND ASSOCIATES INC cn 0-
26 0908689 KUPIETZ, KEVIN DANIEL 76 0908781 BAILEY, BRANDON JAMES 126 0905172 STRICKLAND ASSOCIATES BUILDERS, INC.
27 0909346 RIVER CITY CHURCH 77 0904137 HODGE,WILLIAM A JR 127 0905171 STRICKLAND ASSOCIATES BUILDERS, INC. _ co
28 0904332 DIETTRICH,CLAUDE G 78 0907791 RIECK, ROY J JR 128 0913044 STRICKLAND ASSOCIATES, No oo
co
29 0909345 RIVER CITY CHURCH 79 0903738 MERRITT,THOMAS A&BETSEY B 129 0901153 WALKER,SHIRLEY A BIRDSONG (1/5 INT) N co
30 _ 0909344 UNKNOWN, 80 0904396 FERRELL,CHRISTOPHER S 130 0901779 BAIRD, NICOLE
E.
31 0909343 UNKNOWN, 81 0906065 FERRELL,CHRISTOPHER SCOTT 131 0905696 CHAMBERS, MATTHEW WAYNE (7 1U Z_ N Lo
32 0901593 BEALE, DREWERY N LIVING TRUST 82 0901405 RICKS,WILSON E 132 0905695 CHAMBERS, MATTHEW WAYNE
33 0901082 BEALE, DREWERY N LIVING TRUST 83 _ CANAL 133 0903117 PAUL,AUSTIN C Q C5
34 0901081 BEALE, DREWERY N LIVING TRUST 84 0908513 UPTON, MATTHEW PAUL 134 0901080 JONES,TONYA D o o_
35 0900580 MERCER,G STEPHEN 85 0906252 CARAWAN, KENNETH R 135 0906452 CARTER,AMICA L COLEMAN
36 0900581 MERCER,G STEPHEN 86 0901075 WATTS, PAMELA S 136 0901871 WARD,SHEILA JERKINS
o
37 0903168 MTD INVESTMENTS, INC 87 0902358 WALLACE,G LAYNE 137 0906192 DAVIS,DEBRA W
38 0906138 BROOKS, KENNETH LEWIS JR 88 0901074 RODRIGUEZ, LUIS E 138 0902865 CITY OF ROANOKE RAPIDSDPIg
39 0909335 N C NATURAL GAS CORP, 89 0919621 RODRIGUEZ, LUIS E 139 0904107 CITY OF ROANOKE RAPIDSLILj
40 0905511 PARKER,PERLINE 90 —
0919398 RODRIGUEZ, LUIS E 140 _ 0907724 R&D RENTALS, LLC S
41 0907100 CITY OF ROANOKE RAPIDS 91 0911516 MILLER, ISAAC HENRY III 141 0905801 DIXON,JACOB H NI w N
42 0907259 LANDGROVER,ANGEL L 92 0909270 DOMINION-VIRGINIA POWER, 142 0909437 CITY OF ROANOKE RAPIDS,
43 0907101 CITY OF ROANOKE RAPIDS 93 0911509 BLACKMON,JUSTIN DAVID 143 0908497 ADAMS,TIMOTHY EUGENE 72 Y(7 o z_
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a) o m_o N
44 0903160 FINNEY,ARNOLD L 94 0911440 OVERTON,WILBUR C&JANET T 144 0905800 DIXON,JACOB H a) o>°a'.
m� zo
45 0900361 LOVE, BRETT CAMERON 95 0911412 THANNIKKARY,ALEX C 145 0904037 GARRETT,MILTON JAMES )w g N
Y J ..a
46 _ 0903161 FINNEY,ARNOLD L 96 _ 0908579 FLOYD,COURTNEY J 146 0902732 JEFFERS,COLUMBUS W g Z z
47 0905051 KIDD,WILLIAM E&MARILYN G 97 0906973 WINGFIELD LIVING TRUST 147 0905536 MORNING, FRANCES E(LE) •a Ll a
48 0902232 HARRIS,DANNY FLEETWOOD JR 98 0908655 RIGSBY, MARK LESLIE 148 0902552 DAVIS,JAMES RUDOLPH Z2
49 0902354 JOHNSON,STEVEN J 99 _ 0911391 LEHMAN, D CHRISTIAN 149 0907715 MARROW, ETHEL S(LE)
50 0905044 R&D RENTALS,LLC 100 0906448 PARRISH,WALTER B&EDNA G 150 0902539 MARABLE,QUENTON KENNETH 13) 0
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