NCC230283_FRO Submitted_20230131

Envlra Recelveld uality
SEP 19 2022
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT Winston-Salem
R Tonal office
No person may initiate any land -disturbing activity on one or more acres as covered by the Act bef�te 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.) OACV1 f 202 3,^A
Part A.
1. Project Name Throwing Bent44kV GOAB Replacement
2. Location of land -disturbing activity: County Rockingham City or Township Madison
Horseshoe Road 36.399770°-79.952300'
Highway/Street Latitude(decimal degrees) LOngitude(decimal degrees)
3. Approximate date land -disturbing activity will commence: March 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Transmission Line Rebuild
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.43
6. Amount of fee enclosed: $ 200 The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $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:
Name Eric Shook E-mail Address
Phone: Office # 336-419-9168 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC 704-382-6383 760-445-3332
Name Phone: Office # Mobile #
526 South Church Street, Mail Code EC1090 526 South Church Street, Mail Code EC109Q
Current Mailing Address Current Street Address
Charlotte NC 28202-1006 Charlotte NC 28202-1006
City State Zip City State Zip
Transmission Right -of -Way
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 companyis 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 Carolinas, LLC [e-mail]
Company Name E-mail Address
526 South Church Street, Mail Code EC109Q 526 South Church Street, Mail Code EC109Q
Current Mailing Address Current Street Address
Charlotte NC 28202-1006 Charlotte NC 28202-1006
City State Zip City State
Phone: Office # 704-382-6383 Mobile # [phone]
Zip
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:
C T Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Suite 200
Current Mailing Address Current Street Address
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
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.
Jeff Goto
Type or print na e,
c.
Signature
Lead Permitting Manager
Title or Authority
$/ 2 3I2D i 2-
Date
CL-- OI(LG�� a Notary Public of the County of
State of North Carolina, hereby certify that , 1 eart C`'l.uk-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 J3 day of 20-'Aa
r L Oj__
HELISIA WRIGHT otary
Notary Public, North Carolina
Union County 3 be.)
My Commission Expires My commission expires
March 15, 2027