NCC222132_FRO Submitted_20220609

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. R-2577A Reidsville Road Improvements Part 1
1 Project Name
2. Location of land -disturbing activity: CountyForsyth — —CityorTownshipWinston-Salem
Highway/Street Reidsville Rd Latitude 36.10936 Longitude -80.188981
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): 12.42
6. Amount of fee enclosed: $ 1300 . 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 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. Page No. 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 [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:
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 (Karen Rozar) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court, Suite 200 160 Mine Lake Court, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 Raleigh NC 27615-6417
City
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.
Patrick Sizemore
Type or print name
Signature
Senior Engineering Technologist
Title or Authority
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a Notary Public of the County Of To
State of North Carolina, hereby certify that�'��'Cle__ 31 Ztry'bre_ _ appeared
personally before me this day and being duly swom acknowledged that the above form was
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