NCC215435_FRO Submitted_20210930

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 and/or fax
information unavailable, place NIA in the blank.)
Part A.
1. Project Name_....... Duke Energy —Allen Steam — 30kV Station „ 2
2. Location of land -disturbing activity: County Gaston City or Township Belmont
Highway/Street Canal Road Latitude 35.189157°N Longitude - 81.010904°W
3. Approximate date land -disturbing activity will commence: August 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Electric Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.25
6. Amount of fee enclosed: $ 975 + 2,000 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Neal Care E-mail Address neal.ca![e-mail]
Telephone [phone] Cell # 704-575-3424 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DUKE ENERGY CAROLINAS, LLC 980-373-4228 _NIA
Name Telephone Fax Number
526 South Church Street EC08Q 526 South Church Street, EC08Q
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
10. Deed Book No, 0268 Page No. 0586, See attached.
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship, the name of the owner or manager may be listed as the financially responsible party.
Duke Energy Carolinas, LLC Mike.Robinson(cDduke-ener_a_y.com
Name E-mail Address
526 South Church Street, EC08Q 526 South Church Street EC08Q
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip

Telephone [phone] Fax Number NIA
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
NIA
Name E-mail Address
NIA
Current Mailing Address Current Street Address
NIA
City State Zip City State Zip
Telephone NIA Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
CT Corporation Svstem NIA
Name of Registered Agent E-mail Address
160 Mine Lake Ct., Suite 200 NIA
Current Mailing Address Current Street Address
Raleigh NC 27601 NIA NIA NIA
City State Zip City State Zip
Telephone [phone] Fax Number NIA
(c) In 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:
Burns & McDonnell mgebremicael(a)burnsmcd.com
Engineering Firm or other consultant E-mail Address
Men stab Gebremicael 470-579-5719 NIA
Individual contact person (type or print) Telephone Fax Number
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 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 Person). I agree to provide corrected information should there be
any change in the information provided herein.
Michael D Robinson Manager, Substation Engineering
Type or print nam Title or Authority
3/20�
Signature Date
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I, Baa o013 L G6W%S a Notary Public of the County of fte-CVt-ENBUAG
State of North Carolina, hereby certify that MICIOEL o Ro81N5oN appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 3Ko day of AuGust , 20 21
&,;& 6AFINMa4 Lewis
Notary
Seal
My commission expires S 6 tit 2
3PANDON LEWIS
Notary Public - North Carolina
Mecklenburg County
My Commission Expires Jun 11, 2024