NCC217178_FRO Submitted_20220105

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. 1. Project NameMilburnie 230kV - Yard Rebuild
2. Location of land -disturbing activity: CountyWake City or TownshipRalelgh
Highway/Street Patriots Drive Latitude35.7806 Longitude 78.5544
3. Approximate date land -disturbing activity will commence: December 28, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):20.50 (prev. 7.62)
6. Amount of fee enclosed: $3,300 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 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 $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameReuben Jones
E-mail [e-mail]
Cell # 919-210-2532 Fax # [phone]
Telephone
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Progress, LLC
919-546-2235 919-546-7175
Name
Telephone Fax Number
410 South Wilmington Street
550 South Tryon St, DEC45A
Current Mailing Address
Current Street Address
Raleigh NC 27601
Charlotte NC 28202
City State Zip
City State Zip
10. Deed Book No. Page No.
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, LLC
[e-mail]
Name
E-mail Address
410 South Wilmington Street
410 South Wilmington Street
Current Mailing Address
Current Street Address
Raleigh NC 27601
Charlotte NC 28202
City State Zip
City State Zip
919-546-7451
Fax Number 919-546-7175
Telephone

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
Current Mailing Address
City
State Zip
E-mail Address
Current Street Address
City
Telephone Fax Number
State Zip
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
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:
McAdams [e-mail]
Engineering Firm or other consultant E-mail Address
Patrick Covil 919-287-0795
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
Type or pri name
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Sign &ftfre
Title or Authority
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Date
Notar Public of the County of
State of North Carolina, hereby certify that /Y/000/ (, �/ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
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Witness my hand and notarial seal, this / / day of %X i*_, /
H'4 �/T ��� Notary
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