NCC220895_FRO Submitted_20220224

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. Conley Creek Access Area
1. Project Name
2. Location of land -disturbing activity: County Caldwell City or Township Granite Falls
Highway/Street 5475 Waterworks Rd Latitude 35.787795 Longitude-81.482431
3. Approximate date land -disturbing activity will commence: 4/1 /2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.8
6. Amount of fee enclosed: $ 500 The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ashlie Hood E-mail Address ash lie. [e-mail]
Telephone [phone] cell # 704-307-7880 Fax #
9
Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC 980-373-4183
Name Telephone
526 S. Church Street 526 S. Church Street
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC
City
10. Deed Book No. 144
State
704-382-4671
Fax Number
28202
Zip City State Zip
Page No.1454 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
Name
526 S. Church Street
Current Mailing Address
Charlotte NC
City State
Telephone [phone]
28202
Zip
E-mail Address
526 S. Church Street
Current Street Address
Charlotte NC
City State
Fax Number704-382-4671
28202
Zip

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State
Zip
(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; Attn: Karen Rozar [e-mail]
Name of Registered Agent
160 Mine Lake Ct, Suite 200
Current Mailing Address
Raleigh, NC 27615-6417
City
E-mail Address
Current Street Address
State Zip City
Telephone [phone]
Fax Number
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.
Eric Rouse Director of Land Services
Type or pint name Title or Authority
Signs re Date
I, �%�1111J771 �A S , a Notary Public of the County of nuvv Div
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 J&O jA 2JYM 20
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JAMONICA M FACYSON
Notary Public - North Carolina 9 2Ed
Rowan County N tary
an Ission Expires Jun 18, 2025
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