Loading...
HomeMy WebLinkAboutNCC220898_FRO Submitted_20220225FINANCIAL RESPONSIBILITYIOWNERSHIP 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. 1. Project Name UNIT 5 INACTIVE ASH BASIN IMPOUNDMENT CLOSURE - PHASE 4 EROSION CONTROL PLAN 2. Location of land -disturbing activity: County CLEVELAND AND RUTHERFORO City or Township CLIFFSIDEIMOORESBORO Highway/Street MCCRAW ROAD Latitude 350 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): 6.53 ACRES 2,450 6. Amount of fee enclosed: $ (700 + 1,750) . 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 Enclosedx 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name ELIZABETH GLENN Telephone (864) 642-8833 Cell # E-mail Address Elizabeth.Glenn@Duke-Energy.com Fax # N/A 9. Landowner(s) of Record (attach accompanied page to list additional owners): DUKE ENERGY CAROLINAS, LLC Name 400 SOUTH TRYON STREET, SUITE 30C Current Mailing Address CHARLOTTE NC 28202 City State Zip 10. Deed Book No. 2 1 49 Page No. Telephone Fax Number 400 SOUTH TRYON STREEN, SUITE 30C Current Street Address CHARLOTTE NC 28202 City State Zip 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.) if the company orfirm is a sole proprietorship. the name of the owner or manager may be listed as the financially responsible party. DUKE ENERGY CAROLINAS, LLC Name E-mail Address 400 SOUTH TRYON STREET, SUITE 30C 400 SOUTH TRYON STREET, SUITE 30C Current Mailing Address Current Street Address CHARLOTTE NC 28202 city State Zip CHARLOTTE NC 28202 City State Zip Telephone Fax Number 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 ken.daly@woodplc.com 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. Type or print name Title or Authority Signature Date I, C a Notary Public of the County of State of North Carolina, hereby certify that ZQ_utd Q�,[Qr O appeared personally before me this day and being duly sworn ackngwI d g e d that the above form was executed by him. Witness my hand and notarial seal, this I o day of 2all UNEL R. IPF�.AR Notary Mecklen'guAgilCounty My commission expires O dQ :W North Carolina My Commission Expires 3