NCC220898_FRO Submitted_20220225

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name UNIT 5 INACTIVE ASH BASIN IMPOUNDMENT CLOSURE - PHASE 4 EROSION CONTROL PLAN
2. Location of land -disturbing activity: County CLEVELAND AND RUTHERFORO City or Township CLIFFSIDEIMOORESBORO
Highway/Street MCCRAW ROAD Latitude 350 12' 20.6" N Longitude 810 46' 10.8" W
3. Approximate date land -disturbing activity will commence: Q 1 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): INDUSTRIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.53 ACRES
2,450
6. Amount of fee enclosed: $ (700 + 1,750) . 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 ELIZABETH GLENN
Telephone [phone] Cell #
E-mail Address [e-mail]
Fax # N/A
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. 2 1 49 Page No.
Telephone
Fax Number
400 SOUTH TRYON STREEN, SUITE 30C
Current Street Address
CHARLOTTE NC 28202
City State Zip
0006 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 orfirm is a sole proprietorship.
the name of the owner or manager may be listed as the financially responsible party.
DUKE ENERGY CAROLINAS, LLC
Name
E-mail Address
400 SOUTH TRYON STREET, SUITE 30C 400 SOUTH TRYON STREET, SUITE 30C
Current Mailing Address Current Street Address
CHARLOTTE NC 28202
city
State Zip
CHARLOTTE NC 28202
City State Zip
Telephone 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 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 LAKE 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 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 ENVIRONMENT AND INFRASTRUCTURE SOLUTIONS. INC
[e-mail]
Engineering Firm or other consultant
E-mail Address
Ken Daly
704-222-1438 704-357-8638
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 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.
Type or print name Title or Authority
Signature Date
I, C a Notary Public of the County of
State of North Carolina, hereby certify that ZQ_utd Q�,[Qr O appeared personally
before me this day and being duly sworn ackngwI d g e d that the above form was executed by him.
Witness my hand and notarial seal, this I o day of 2all
UNEL R. IPF�.AR Notary
Mecklen'guAgilCounty My commission expires O dQ :W
North Carolina
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