HomeMy WebLinkAboutNCC232004_FRO Submitted_20230703 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 Duke Energy - Dunn Mobile Substation Storage and Operations Center
2. Location of land-disturbing activity: County H am ett City or Township Dunn
Highway/Street 1269 Jonesboro Road Latitude(decimal degrees) 35.3196 -78.5628
Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 1 2/01/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 32.75
6. Amount of fee enclosed 3'300 + 2,000 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 D Enclosed El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Nuwan Wijesuriya E-mail Address nuwan.wijesuriya@duke-energy.com
Phone: Office# 919.546.2090 Mobile# 919-931-6655
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Duke Energy Progress LLC C/O
.Data & Document Management
Name Phone: Office# Mobile#
526 South Church St. ECII-05 526 South Church St. ECII-05
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
10. Deed Book No.4145 Page No.0654 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).
Duke Energy Progress LLC nuwan.wijesuriya@duke-energy.com
Company Name E-mail Address
411 Fayetteville St. 410 S. Wilmington St
Current Mailing Address Current Street Address
Raleigh NC 27601 Raleigh NC 27601
City State Zip City State Zip
Phone: Office# 919-546-2090 Mobile# 919-931 .6655
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 ct-statecommunications@wolterskluwer.com
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#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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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.
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 prado@mcadamsco.com
Engineering firm or other consultant E-mail Address
Claudia Prado, PE 919.361 .5000 704.650.2984
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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Title or Authority
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Signature U Date
I,i4o . , TMjlir Maki c tiu'+or-, a Notary Public of the County of Ural= d
State of North Carolina, hereby certify that WItwiun. .c uri UA 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 Lb day of J WU- , 20 Z S
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THE JOHN R.MCADAMS COMPANY,INC
i 621 HILLSBOROUGH ST STE 500 66-46/531
RALEIGH,NC 27603 CHECK DATE
(919)361-5000 June 16, 2023
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PAY Two Thousand and 00/100 Dollars
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TO NCDEQ VOID AFTER 180 DAYS 8
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THE JOHN R.MCADAMS COMPANY,INC.
621 HILLSBOROUGH ST STE 500 66-46/531
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(919)361-5000 June 16, 2023
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PAY Three Thousand Three Hundred and 00/100 Dollars
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AMOUNT 3,300.00
TO NCDEQ VOID AFTER 180 DAYS N
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