NCC230908_FRO Submitted_20230331

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 Fairview Tie to McDowell Tie OPGW (Logan/Fairview OPGW)
2. Location of land -disturbing activity: County Rulherford-McDowell City or Township Forest City - Marion
10th St NE 35.349328' -81 894425'
Highway/Street Latltude(deamal degrees) Longltude(deamal degrees)
3. Approximate date land -disturbing activity will commence: March 31, 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): 58.85 aC
6. Amount of fee enclosed $2,000 & $5,900 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, after which 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:
Name Neal Cary E-mail Address [e-mail]
Phone: Office # [phone] Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC 704-382-6383
Name Phone: Office #
526 South Church Street, EC1 09Q
Current Mailing Address
Charlotte NC 28202-1006
City State Zip
Current Street Address
City
State
760-445-3332
Mobile #
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 mdividual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies)
Duke Energy Carolinas, LLC
Company Name
526 South Church Street, EC1 09Q
Current Mailing Address
Charlotte NC 28202-1006
[e-mail]
E-mail Address
Current Street Address
City
State Zip
City State Zip
Phone:
Office # 704-382-6383
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 System [e-mail]
Name of Registered Agent
160 Mine Lake Court, Suite 200
Current Mailing Address
Raleigh NC 27615-6417
City State Zip
Phone: office # [phone]
Karen Rozar
E-mail Address
Current Street Address
City State Zip
Mobile #
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:
HDR
Engineering firm or other consultant
Brooke Ahrens
Individual contact person (type or print)
[e-mail]
E-mail Address
Phone: Office #
704-338-6847
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.
Jeff Goto
Lead Permitting Manager
Type or print name Title or Authority
03/1`1 �2023
Si ature Date
TA6 , a Notary Public of the County of (1111 ti I-ru C
State of North Carolina, hereby certify that 69k 0 ` 1 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 day of 1, 20 ��
ASHTON CARTER
Notary Public - North Carolina
Guilford County
My commission Expires August 12. 2W6
a `
_ftt5�j (47&-
Notary t
My commission expires (ASy I- �Z!�