Loading...
HomeMy WebLinkAboutNCC221515_FRO Submitted_20220420FINANCIAL 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. Roxboro Borrow Area 8 Plan 1. Project Name 2. Location of land -disturbing activity: County Person City or Township Semora Highway/Street Dunnaway Rd Latitude 36.484682 Longitude -79.058439 3. Approximate date land -disturbing activity will commence: Spring 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 83.0 Acres 6. Amount of fee enclosed: $ 83 x $100 = $8,300 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 NSA No NSA Enclosed X 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Duncan Brewer E-mail Address Duncan.Brewer@duke-energy.com Telephone 336-330-2058 Cell # 336-330-2058 Fax # 919-546-7175 9. Landowner(s) of Record (attach accompanied page to list additional owners): Duke Energy Progress, LLC (800) 777-9898 919-546-7175 Name Telephone Fax Number PO Box 1551-PEB3A 1700 Dunnaway Rd Current Mailing Address Current Street Address Raleigh NC 27602 Semora NC 27343 City State Zip City State Zip 10. Deed Book No. 98 Page No. 267 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 maybe listed as the financially responsible party. Duke Energy Progress, LLC duncan.brewer@duke-energy.com Name E-mail Address 1700 Dunnaway Road 1700 Dunnaway Road Current Mailing Address Current Street Address Semora NC 27343 Semora NC 27343 City State Zip City State " Zip 336-330-2058 91 g-546-7175 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: N/A N/A Name E-mail Address N/A N/A Current Mailing Address Current Street Address N/A N/A N/A N/A N/A N/A City State Zip City State Zip Telephone N/A Fax Number N/A (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: N/A N/A Name of Registered Agent E-mail Address N/A N/A Current Mailing Address Current Street Address N/A N/A N/A N/A N/A N/A City State Zip City State Zip N/A Fax Number N/A Telephone, 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. �C Vl Cct vt D ce-Lez-/ 6 fU L' Ct Ye C( c -r Type or riot name Title or Authority Si nature Date I, )�qe'i f (/v( GC n/i , a Notary Public of the County of IN a JQ State of North Carolina, hereby certify that H JL'-'/ I 01(A n P r-e'"le-appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. tLWitness my hand and notarial seal, this day of /A `�,oC � , 20 a � _ �, Notary Reawr O, _ AL81`G My commission expires