NCC241471_FRO Submitted_20240529

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Marshall Soil Borrow Area 3 E&SC Plan
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land disturbing activity: County Catawba City or Township Terrell
Highway/Street 8320 NC-150 Latltude(decima degrees)35.5969 Longitude(decimal degrees) -80.9663
3. Approximate date land-disturbing activity will commence: 1/1/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 66.0 Acres
6. Amount of fee enclosed: $$6,600.00 . 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 Cl No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name J. Scott La Sala E-mail Address [e-mail]
Phone: Office# 828-478-7820 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC 704-382-4585 N/A
Name Phone: Office# Mobile#
525 South Tryon Street 525 South Tryon Street
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
10. Deed Book No.2954 Page No.42 1-428 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 Carolinas, LLC N/A
Company Name E-mail Address
525 South Tryon Street 525 South Tryon Street
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
Phone: Office# 704-382-4585 Mobile# N/A
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 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# N/A Mobile# N/A
N/A
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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.
N/A
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.
David Dellario GM CCP Project Management
Type or print nam Title or Authority
///ao/23
Signature Date
I, <.), LJ 1 Q S , a Notary Public of the County of 1 if t L r,
State of North Carolina, hereby certify that DAV,. A �P t I c r t'o appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
i �
Witness my hand and notarial seal, this D 1 day of IvI CJ ty1 j Qy , 20 a3
Nota 1
My commission expires My Commission Expires 7-28-2027