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HomeMy WebLinkAboutNCC222784_FRO Submitted_20220804FINANCIAL 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 N/A in the blank.) Part A. 1. Project NamePorters Neck - Castle Hayne - Folkstone 230kV 2. Location of land -disturbing activity: County New Hanover City or Township Kirkland Highway/Street Porters Neck Road Latitude(decimaldegrees) 34.321 Long itude(decimaldegrees) _77.820 3. Approximate date land -disturbing activity will commence: 8/15/2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): electrical transmissi^i 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20.0 6. Amount of fee enclosed K000.00 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 x❑ No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: NameNuwan Wijesuriya E-mail Address nuwan.wijesuriyaC@duke-energy.com Phone: Office # 919-546-2090 Mobile # 919-931-6655 9. Landowner(s) of Record (attach accompanied page to list additional owners): Duke Energy Progress, LLC 919-546-2090 Name 410 South Wilmington Street Current Mailing Address Raleigh NC 27601 City Phone: Office # Mobile # 410 South Wilmington Street Current Street Address Raleigh NC 27601 State Zip City State Zip 10. Deed Book No. Page No. 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.) If 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 Progress, LLC nuwan.wijesuriyaC@duke-energy.com Company Name 410 South Wilmington Street Current Mailing Address Raleigh NC 27601 E-mail Address 410 South Wilmington Street Current Street Address Raleigh NC 27601 City State Zip City State Zip Phone: Office # 919-546-2090 Mobile # 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 ct-statecommunications@wolterskluwer.com 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 Raleigh NC 27615 City State Zip City State Zip Phone: Office # 919-844-8360 Mobile # Karen Rozar 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # 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. 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: McAdams covil@mcadamsco.com Engineering firm or other consultant E-mail Address Patrick Covil 919-287-0795 Individual contact person (type or print) Phone: Office # 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. Nuwan Wijesuriya Lead Transmission Permitting Manager Type or print name Title or Authority Signature Date I, MR.'"S /.,. pzm1w JIL , a Notary Public of the County of V4eU K State of North Carolina, hereby certify that Hti Wb-N W 1JC <09-tqA _ appeared personally before me this day and being duly sworn acknowledged that the above r was executed by him/her. Witness my hand and notarial seal, this 21 day of 207 A141� � Puibv Notary My commission expires v h 7474