NCC240405_FRO Submitted_20240216

Check if this project is ARPA-funded ❑
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
o person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
_ctivity under a common plan of development of this size as covered by the NCGO1 permit, before this form
-nd an acceptable erosion and sedimentation control plan have been completed and approved by the Land
•uality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
egional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
umber is unavailable, place N/A in the blank.)
'art A.
. Project Name Line 12 Distribution Pipeline Project
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
'. Location of land-disturbing activity: County Wilson City or Township Wilson
Highway/Street Linear Right-of-Way Latltude(decimal degrees)35.702981 Longitude(decimai degrees)-77.874743
Approximate date land-disturbing activity will commence: January 2024
Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial (Utility)
Total acreage disturbed or uncovered (including off-site borrow and waste areas): 9.50
s,. Amount of fee enclosed: $ ($100 x 10)=$1,000 . 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑ No IZ
Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Justin Andrews E-mail Address Justin.Andrews aC�duke-energy.com
Phone: Office# 252-641-8425 Mobile# [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Piedmont Natural Gas [phone] n/a
Name Phone: Office# Mobile#
4720 Piedmont Row Drive 4720 Piedmont Row Drive
Current Mailing Address Current Street Address
Charlotte NC 28210 Charlotte NC 28210
City State Zip City State Zip
11. Deed Book No. See attached Page No. See attached Provide a copy of the most current deed.

"art B.
. 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).
Piedmont Natural Gas n/a
Company 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 Zip City State Zip
Phone: Office# [phone] Mobile# n/a
ote: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
he landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
ontrol plan and to conduct the anticipated land disturbing activity.
'. (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 [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court, Ste 200 n/a
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 n/a
City State Zip City State Zip
Phone: Office# 919-844-8360 Mobile# n/a
Karen Rozar
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
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.
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.
Justin Andrews Sr Distribution Project Specialist, NGBU
Type or ' me Title or Authority
//-• /`ti-01.3
gnature Date
I, rct-n A . e...l , a Notary Public of the County of P_.c.--rnlae_
State of North Carolina, hereby certify that J Lk.Sir-►r•1 Arc cA..s5 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 IL) day of Nbvc.rc e.c' , 20 a3
irrio. a )44 tiL
*.`N,,,,spat ...... • 4- �,, Notary
=m . My My commission expires J9D-� - j 2 bZ1
.0.•1„ltill,,,,,

ontinued 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.
andowner 2 of Record:
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.
andowner 3 of Record:
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.
L:ndowner 4 of Record:
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.
L;ndowner 5 of Record:
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.

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