NCC220615_FRO Submitted_20220203

FINANCIAL RESPONSIBILITYJOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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.
Project Name iCliiiiside Unit 5 SWiEt&ryaTd Storm kn Re70r,eri
Location of land -disturbing activity: County
City or Township T,
Highway/Street 573 Ek*e Power Rd_ Latitude .32161ii B-N Longitude 81
3. Approximate date land -disturbing activity will commence: Winter2U22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Isfirl
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
52 ages
6. Amount of fee enclosed: $ 390 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $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 Brandon Lewis E-mail Address Brandon.Lewis20duke-energy.com
Telephone [phone]
Cell # 704-674-4536 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas LLC
Name
526 S. Church Street, EC08Q
Current Mailing Address
980-373-4228
Telephone Fax Number
526 S. Church Street, EC080
Current Street Address
Charlotte
NC
28202
Charlotte NC
28202
City
State
Zip
City State
Zip
10, Deed Book No.
See Attachment
Page No.
See Attachment provide a copy of the most
current deed.
Part B.
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
526 S. Church Street, EC08Q
Current Mailing Address
Charlotte NC 28202
City State Zip
Telephone [phone]
M i ke. Robin [e-mail]
E-mail Address
526 S. Church Street, EC08Q
Current Street Address
Charlotte NC 28202
City State Zip
Fax Number

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
Telephone
E-mail Address
Current Street Address
Zip City
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:
Cam_ oration System
Name of Registered Agent
160 Kline Lace Ct-, .Suite 200
Current Mailing Address
City
State Zip
Telephone 'SG-373-4228
Mike R mso n@duke- gy.C=
E-mail Address
526 S- Church Street, ECO80
Current Street Address
City
Fax Number
_ 2B2aj2
State Zip
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
Type or print name
2 � �' 79W
Signature
Manager, Substation Engineering
Title or Authority
=' 6 l2 0.2
Date
I w , a Notary Public of the County of 146CKLEMBORG
State of North Carolina, hereby certify that —MiruAel_ a RQRtNsntj 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 16r" day of SEnTEMR57.R , 20 21
Seal
------------
BPANQON LEW15
Notary Public - North Carolina
Mecklenburg County
My Commission Expires Jun 11, 2024
&/.aJ�1_ij(Notary
My commission expires JUME 11 J 2024,