NCC220075_FRO Submitted_20220105

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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 NIA in the blank.)
Part A. ACTIVE ASH BASIN - PHASE 0 (VEGETATION CLEARING) EROSION CONTROL PLAN
1. Project Name
2. Location of land -disturbing activity: County CLEVELAND AND RUTHERFORD CL USIDEIMOORESSOROCity or Township
Highway/Street MCCRAW ROAD Latitude 35" 12' 20.6" N Longitude 810 46' 10.8" W
3. Approximate date land -disturbing activity will commence Q 1 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): INDUSTRIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 22.44 ACRES
4 300
6. Amount of fee enclosed. $ (21 10 + 2.000) . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2 000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes- No Enclosed X
8. Person to contact should erosion and sediment control issues arise durnng land -disturbing activity:
Name ELIZABETH GLENN E-mail Address Elizabeth [e-mail]
Telephone [phone] Cell # Fax # NIA
9 Landowner(s) of Record (attach accompanied page to list additional owners):
DUKE ENERGY CAROLINAS, LLC [phone]
Name Telephone Fax Number
400 SOUTH TRYON STREET, �400 SOUTH TRYON STREEN, SllTE-�
Current Mailing Address r,, Current Street Address 7-d'�qK
CHARLOTTE NC 28202 CHARLOTTE NC 28202
City State Zip City State Zip
10. Deed Book No. 2 1 49 Page No_ 0006 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.) +fthe company or firm is a sole proprietorship,
the name of the owner or manager maybe listed as the financially responsible party.
DUKE ENERGY CAROLINAS, LLC
Name
400 SOUTH TRYON STREET. SUITE 30C
Current Mailing Address
CHARLOTTE NC 28202
City
State Zip
Telephone [phone]
E-mail Address
400 SOUTH TRYON STREET, SUITE 30C
Current Street Address
CHARLOTTF,N _'� �} 2842
City Yp• u, State iglAi;'eiki Zip
Fax Number" ' -- _ _` iFnn VM

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip
City State Zip
Telephone
Fax Number
(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:
CT CORPORATION SYSTEM
NIA
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
Telephone N/A
Fax Number N/A
(c) In 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:
WOOD ENVIRONMENT AND INFRASTRUCTURE SOLUTIONS INC
[e-mail]
Engineering Firm or other consultant
E-mail Address
Ken Daly
704-222-1438 704-357-8638
Individual contact person (type or print)
Telephone Fax Number
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.
Ty= or print na
Signature
Title or Authority
Date
a Notary Public of the County of t
State of North Carolina, hereby certify that _ �' 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 20�
UUAIEL A. SPEAR Notary
NOTARY PUBLIC My commission expires.
Mecklenburg County �r
North Carolina
My Commission Expires a.