NCC220497_FRO Submitted_20220126

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. U-4015A Work Order Number: 36575533
1. Project Name
2. Location of land -disturbing activity: County: u- rd City or Township Greensboro
Highway/Street Gallimore Dairy Road Latitude 36.065118 Longitude-79.957942
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Energy Infrastructure
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.87
6. Amount of fee enclosed: $ 500 . 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Patrick Sizemore E-mail Address [e-mail]
Telephone [phone] Cell # 336.416.8632 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Utility Easement
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. N/A Page No. N/A 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 companyorfirm 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
526 South Church Street 500 Utility Drive
Current Mailing Address Current Street Address
Charlotte, NC 28202 Clemmons, NC 27012
City State Zip City State Zip
Telephone [phone] Fax Number 336.917.2510

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:
NIA
Name
NIA
Current Mailing Address
NIA
City
Telephone N/A
State Zip
NIA
E-mail Address
NIA
Current Street Address
NIA
City State Zip
Fax Number NIA
(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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
City
NIA
E-mail Address
NIA
Current Street Address
NIA
State zip City
Telephone N/A Fax Number N/A
State Zip
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.
Patrick Sizemore
Type or print nam
Signature
Senior Engineering Technologist
Title or Authority
Date
I, , a Notary Public of the County of f,U� t h
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
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Wit ; ��d�r4,d 6Orial seal, this CN I day of P 20 01
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