NCC215545_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20240410

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead,you must submit a new NCG01 electronic Notice of Intent (eNOI).
Directions:
Print this form, complete,scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Certificate of Coverage (COC) Number: NCC215545
Name of Project: Unit 5 Inactive Ash Basin-Closure Excavation Ph. 2 (Express Review)
Legally Responsible Organizational Entity: Duke Energy Carolinas, LLC
Eric Kinstler was Previous LRL Please let me know if we need to send
PREVIOUS Legally Responsible Individual: David Dellario annthor Change Form,or ifjnn can update and arrant when you
NEW Legally Responsible Individual: Eric Szkolnyj receive the original.
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.GB(l), any person who knowingly makes any false statement, representation,
or certification in any application, record, report,plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars($10,000).
Page 1 of 2

n v m Ln
C
d O O } � rt rr 1 S
z. � av o ED = rD az' ® L� Lam' L� R'
O O r - 1+ n�i 000
cCD
D CmCL
m
Q
n 0 2 C Q a G� m s - m � m m m r��o
6 N �fDD Q � p H Q. '� C rD — r-r •C
Q N to = rD Ai �• `* O zZ
4n 4 O Ln N p h ID Cr :� rD l !
n v as -* a rD
O O O rr p a -a
d
c
O Or lC Q0 N U9 rD Gl y (D O rt r
O O Ln y CD n' cn wNJ v n� rt {D Q —
O h O N O Ln Z; @ Q v (D
O cu rt 3 O m O n rt fD
tp" K OC', W Q �r n y O -V O fD
O O rD � rt �}
O rD (D rD 0 Q `-r rD
mrD (7 `�
O C rrb m (pp .�+ {f O Q C r+ Q Cn Q
rD M
C Ln N N CS (� S2D (D Q O L1 r* O T. r7'I
Q h
r0 r�-r r„ � M w W O p ((DD -„ S m V1
O N rD rD O rD O (D — Q M
ro a o p a, rD o Cr
rb + •* v rD Gl :30 CD
x
_ en
fD rD rf) o f) rD `� w - G. O n
� L N N (D �i h -0 O O O rr n. Z cr
(D O O pp � c cu rD -9 n a Q 0 f D
N r-r O y O O rD r'1 ._� (D �__ nl
N _ Q
N ? N
rD
n) = rD
r�0 O n 'O v, rt „' o� v '_�. Q _
ff Z O Q = ' = p v rD O r'
n c rt h rD
C'
rD O Q 3 = cu
m z CL
,y, O Ct 3 Q —W' fD in —1
d Q 6 oi rD rt rt (D iO
Ln -a D L n rt m n
rp '^
(D �
O rD
O O O :* O DJ
rr 4 C CL
.� O C 0
O _ G CD w rD
CL
p rt rt m
C) O 3 O G _ Q
Q '3
�-` `�° ~ (D vrti O 0
O O ^ UQ p
O a O O O r* O
b R Q r. �rb
rb m (D C
O rt N
r S O N
O
7