NCC230694_FRO Submitted_20230316

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 PITTSBORO HANKS CHAPEL 230kV SUBSTATION
2. Location of land -disturbing activity: County CHATHAM City orTownship PI ITI `7BORO
Highway/StreetLUCIAN BLAND RD Latltude(decimaldegrees) 35,714914Long itude(decimaldegrees) _-719,13884a
3. Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_ Electrical Substation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 1 1.03
6. Amount of fee enclosed 3,200 �. 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nuwan Wijesuriya E-mail Address [e-mail]
Phone: Office # [phone] Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners).
DUKE ENERGY PROGRESS, LLC. [phone]
Name Phone: Office # Mobile #
410 South Wilmington Street 410 South Wil-mington Street
Current Mailing Address Current Street Address
_Raleigh NC 27601 Raleigh NC 27601
City State Zip City State Zip
10. Deed Book No. 2004 Page No. 373 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).
Nuwan Wijesuriya
Company Name
410 South Wilmington Street
Current Mailing Address
Raleigh NC 27601
City StateZip
Phone: Office # [phone]
[e-mail]
E-mail Address
410 South Wilmington Street
Current Street Address
Raleigh NC 27601
City State Zip
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 [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Ste 200 160 Mine Lake Ct, Ste 200
Current Mailing Address
Raleigh NC 27615
Current Street Address
Raleigh NC 27615
City State Zip City
Phone: Office # 91 9-844-8360 Mobile #
Karen Rozar
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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
Zip
(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
(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:
McAdams
[e-mail]
Engineering firm or other consultant E-mail Address
Patrick Covil 919-287-0795
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.
Nuwan Wijesuriya
Lead Transmission Permitting Manager
Type or print name Title or Authority
A O 2 �—
Signature Date
I, 7css r_W L P".1k a Notary Public of the County of DwrI,GLm
State of North Carolina, hereby certify that ri appeared personally
before me this day and being duly sworn acknowledged that t e above Of m was executed by him/her.
Witness my hand and notarial seal, this=day of &4VS-i— , 20IL
Gtgg;"
Wake County, North Carolina Ty
ary
Notary Public
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