NCC215756_FRO Submitted_20211015

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 N/A in the blank.)
Part A. DEP Garner White Oak 230kV Substation Bank #2 Addition
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Garner
Highway/Street Ackerman Rd. Latitude -78.578098 Longitude 35.669971
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Electrical Substation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): T 3 +�
6. Amount of fee enclosed: $ 2,000+$520 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per 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). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Brian Lowther E-mail Address [e-mail]
Telephone [phone] Cell # 919.215.4244 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Progress 919.546.7169
Name Telephone Fax Number
411 Fayetteville St. 411 Fayetteville St.
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
10. Deed Book No. 8757 Page No. 213 Provide a copy of the most current deed.
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 Progress [e-mail]
Name
411 Fayetteville St.
Current Mailing Address
E-mail Address
411 Fayetteville St.
Current Street Address
Garner NC 27529 Garner NC 27529
City State
Telephone [phone]
Zip City State
Fax Number
Zip

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:
Name
E-mail Address
Current Street Address
Current Mailing Address
City State Zip
City State Zip
Telephone
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:
Karen Rozar C T Corporation
[e-mail]
Name of Registered Agent
E-mail Address
160 Mine Lake Court, Suite 200
526 South Church Street
Current Mailing Address
Current Street Address
Raleigh NC 27615
Charlotte NC 28202
City State Zip
City State Zip
Telephone [phone]
Fax Number
(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:
Appian Consulting Engineers, P.A.
[e-mail]
Engineering Firm or other consultant
E-mail Address
David C. Revoir, P.E.
252.972.7703
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.
Alan Lewis
Manager, Transmission Substation Engineering
Type or pri mo
Title or Authority
Sig a
Date
I, ^_J t (� rl l t�— 62 S a Notary Public of the County of W o LL
State of North Carolina, hereby certify that kl Pa
� [ a ,W 1,} 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 day of , 20l a— I
"NGPSSE�� i.� Nofa6 V
I (
Seal �ZJS
Z o p y v My commission expires l 04
W—
%Of
KE G0`��