NCC222891_FRO Submitted_20220812

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Duke Energy Toyota Tap 100kV Transmission Line
1. Project Name gY Y p
2.
Location of land -disturbing activity: County Guilford / Randolph City or Township Climax
Highway/Street Hunt Road Latitude 35.91044330 Longitude-79.76002920
3. Approximate date land -disturbing activity will commence: August 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.
Industrial (Utility)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 117.0
6. Amount of fee enclosed: $ $ 1 1 , 700 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eric Shook E-mail Address [e-mail]
Telephone [phone] Cell # n/a Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC 760-445-3332 n/a
Name Telephone Fax Number
EC090 526 South Church Street 526 South Church Street
Current Mailing Address
Charlotte NC 28202
City State Zip
10. Deed Book No. listed on plans Page No.
Current Street Address
Charlotte NC 28202
City State Zip
listed on plans provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Duke Energy Carolinas, LLC [e-mail]
Name E-mail Address
EC090 526 South Church Street 526 South Church Street
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
Telephone [phone] Fax Number Na

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
n/a
Name
n/a
Current Mailing Address
n/a
City
Telephone n/a
n/a
E-mail Address
n/a
Current Street Address
n/a
State Zip City State Zip
Fax Number n/a
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Karen Rozar (CT Corporation System) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court, Ste 200 n/a
Current Mailing Address
Raleigh NC 27615-6417
City State Zip
Telephone [phone]
Current Street Address
n/a
City State Zip
Fax Number n/a
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Jeffrey Goto
Type or print nam
Z:O",
Si nat e
Lead Permitting Manager
Title or Authority
(, I 111, 1 20 22
Date
1, i"f� �1 S t Q �/V �!� a Notary Public of the County of
State of North Carolina, hereby certify that �\ e ln appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this ��day of �� 2Q
HELISIA WRIGHT ota y
N§�6%lpubiic, North Carolina
Union County My commission expires Marc [ 5 a6p
My Commission Expires 'r'
March 15, 2027