NCC230214_FRO Submitted_20230125

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 N/A in the blank.)
Part A.
1. Project Name Cape Fear 63/70 Basin Haul Road
2. Location of land -disturbing activity: County Chatham City or Township MOncure
500 C P and L Road 35.586503-79.049425
Highway/Street LatltUdetdeGma)aegrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: Upon Permit Receipt
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.10 Acres
(51001(
3)=5300 & ($2504)=$750
6. Amount of fee enclosed . 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
A
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Issa J. Zarzar E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Progress, LLC. (919)-546-7574
Name
PO Box 1551 - PEB3A
Current Mailing Address
Raleigh, NC 27602
City
State
[phone]
Phone: Office # Mobile #
500 C P and L Road
Current Street Address
Moncure, NC 27559
Zip City
State
Zip
10. Deed Book No. 1555 page No. 20 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 orif 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 (Attn:lssa Zarzar)
Company Name
PO Box 1551 - PEB3A
Current Mailing Address
Raleigh, NC 27602
[e-mail]
E-mail Address
500 C P and L Road
Current Street Address
Mocure, NC 27559
City State Zip City State Zip
Phone: Office # (919)-546-7574 Mobile # [phone]
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 [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct., 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 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:
WSP USA Environmental and Infrastructure, Inc.
Engineering firm or other consultant
Jeffrey Perrone
Individual contact person (type or print)
[e-mail]
E-mail Address
Phone: Office #
[phone]
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.
Issa J. Zarzar
Type or print name
Signature
GM CCP Project Management
Title or Authority f
\k 15l / 2--
Date
I, ,a Notary Public of the County of L".., VA
State of North Carolina, hereby certify that 1 S5� �f. 7����.o.r' 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 q day of Alomku� , 20-2,0-
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N6taryO
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