NCC220852_FRO Submitted_20220222

NC Dept of Environmental Quality
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM FEB 0 9 21R2
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
No person may initiate any land -disturbing activity on one or more acres as covere y t ht e�nel Office
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. Roxboro Bioreactor Demolition and Erosion and Sediment Control Plan
1. Project Name
2. Location of land -disturbing activity: County Person City or TownshipSemora
Highway/Street Dunnaway Road Latitude 36.471095 Longitude-79.078701
3. Approximate date land -disturbing activity will commence: Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5.
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.5 Acres
(511 oo)-(5*$250)=s1750
6. Amount of fee enclosed: $ . 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 Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ronnie Goodman E-mail Address [e-mail]
Telephone [phone] cell # 812-557-1155 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Progress, LLC 800-777-9898 919-546-7175
Name Telephone Fax Number
PO Box 1551-PEB3A 1700 Dunnaway Road
Current Mailing Address Current Street Address
Raleigh, NC 27602 Semora, NC 27343
City State Zip City State Zip
10. Deed Book No. 98 Page No. 267 and others 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
400 S Tryon St. ST06K 550 S Tryon St
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 NIA
Name E-mail Address
NIA NIA
Current Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
Telephone NIA Fax Number NIA
(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:
NIA NIA
Name of Registered Agent E-mail Address
NIA NIA
Current Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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 EMS [e-mail]
Engineering Firm or other consultant E-mail Address
Adam Pilarz 919-699-2463 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.
Eric J. Szkolnyj GM CPP Regional O&M
Type or t am e Title or uth rity
Signature Date
I,LQ CO r a Notary Public of the County of
State of North Carolina, hereby certify that L rj c. appeared persona
before me this day and being duly sworn acknowledged that the above form was uted by him.
Witness my hand and notarial seal, thisr`��day of , 20
Notary
MU�i R.
NOTARY P661 E My commission expires ZL3. a c�
Mecklenburg County
North Carolina
My Commission Expires