NCC216542_FRO Submitted_20211122

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 Environment and Natural Resources. (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 6 INACTIVE ASH BASIN - CLOSURE EXCAVATION PHASE v
CLEVELAND AND
2. Location of land -disturbing activity: County RUTHERFORD City or Township CLIFFSIDEi MOORESBORO
Highway/Street MCCRAw ROAD Latitude35t 12' 20.6° NLongitude 81° 46' 10.8" W
3. Approximate date land -disturbing activity will commence: Q4 2021
4. Purpose of development (residential, commercial, industrial, institutional. etc.):INDUSTRIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.94 ACRES
2,845
6. Amount of fee enclosed; $ (845+2,000) , 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 ELIZABETH GLENN
Telephone [phone] Cell#
E-mail Address Elizabeth. Glenn-n}Duke - Energy. com
Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DUKE ENERGY CAROLINAS, LLC
Name
400 SOUTH TRYON STREET, SUITE 30C
Current Mailing Address
CHARLOTTE NC 28202
City State Zip
10. Deed Book No. . -
864-642-8833
Telephone
Fax Number
400 SOUTH TRYON STREET, SUITE 30C
Current Street Address
CHARLOTTE 28202
City
State
5
Page No. 001�. Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
DUKE ENERGY CAROLINAS, LLC
Name
400 SOUTH TRYON STREET, SUITE 30C
Current Mailing Address
CHARLOTTE NC 28202
City State Zip
Telephone [phone]
E-mail Address
400 SOUTH TRYON STREET, SUITE 30C
Current Street Aa*, R—J�Ii�I:M '�
j OU8304YRATOIA
CHARLOTTE y!nuo'0 fp2iia'A3eM 28202
City
z a�siew_tioEaafrtr�ttiJ rM � Zip
Fax Number M

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 Mailing Address Current Street 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:
CT CORPORATION SYSTEM
NIA
Name of Registered Agent
E-mail Address
160 MINE SAKE CT, STE 200
160 MINE LAKE CT, STE 200
Current Mailing Address
Current Street Address
RALEIGH NC
27615 RALEIGH NC 27615
City State
Zip City State Zip
Telephone
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:
WOOD ENVIRONMENT AND
INFRASTRUCTURE SOLUTIONS, IN--.'.
en.daly moodplc.Com
Engineering Firm or other consultant
E-mail Address
Ken Daly
704-222 1438 57-8638
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 w4h 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.
tAU i I ik&do
Type or print name
Signature
a
Title or Authority
///z/Z/
Date '
Public of the County of
State of North Carolina, hereby' certify that LJU k}t cA A 1110 rl c 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 aday of Qcpunr4jr, 20e-Ni
MURIEL R. SPEAR Notary
NOTARY PUBLIC
Seallenburg County .�
North Caroline My commission expires ocf I 3
My Cgmmission ExpiresQLL