NCC221882_FRO Submitted_20220518

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Marshall CAMA CAP Well Installation - Phase II (CATAW-2020-017 MODIFICATION)
2. Location of land -disturbing activity: County Catawba Cityor Township Sherrils Ford
Highway/Street 8320 NC -15 0 Latltude(dedmal degrees) 3 5.5969 Longitude(dadmai degrees) - 8 0.966322
3. Approximate date land -disturbing activity will commence: Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
24.2 acres (existing 15.2
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):acres plus 9. o acres of
additional area)
6. Amount of fee enclosed$2, 900 (2000+900)The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Randazzo
E-mail Address chris . randazzo@duke-energy. com
Phone: Office# 704-999-7661
Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC
704 382-4585 N/A
Name
Phone: Office # Mobile #
526 S Church Street
526 S Church Street
Current Mailing Address
Current Street Address
Charlotte, NC 28202
Charlotte, NC 28202
City State Zip
City State Zip
10. Deed Book No. 2 954 Page No.
4 21-42 a Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) !f the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Duke Energy Carolinas, LLC
Company Name
526 S Church Street
Current Mailing Address
Charlotte, NC 28202
City State Zip
Phone: Office# 704-382-4585
N/A
E-mail Address
526 S Church Street
Current Street Address
Charlotte, NC 28202
City State Zip
Mobile # N/A
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
CT Corporation System
Name of Registered Agent
160 Mine Lake Court, Suite 200
Current Mailing Address
Raleigh, NC 27615
City State Zip
N/A
E-mail Address
160 Mine Lake Court, Suit:,:
Current Street Address
Raleigh, NC 27615
City State Zip
Phone: Office # _ N/A Mobile # N/A
N/A
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
N/A
Name of Registered Agent
N/A
E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office # N/A Mobile # N/A
N/A
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
N/A
Company DBA Name
(d) If 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 & Infrastructure Solutions [e-mail]
Engineering firm or other consultant E-mail Address
Chad N. Brown, P.E.
Individual contact person (type or print)
704-357-5612
Phone: Office #
980-297-1100
Mobile #
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
David Dellario
Type or print name
Signature
GM CCP Project Management
Title or Authority
31z,� / zz
Date
I,� , a Notary Public of the County of
State of North Carolina, hereby certify that N14PI
.0 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this y of .2
Notary
MURIEL R. SPEAR
ms"YPUBUO My commission expires N1, :n
Mecident wo County
North Carolina

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
City State
Phone: Office #
Company 3 Name
Current Mailing Address
City State
Phone: Office #
Company 4 Name
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Street Address
Zip City
Mobile #
E-mail Address
State
Zip
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Zip