NCC220894_FRO Submitted_20220225

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 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. U-6003 WO# 29413005
1. Project Name
2. Location of land -disturbing activity: County Forsythe City or Township Kernersville
Highway/Street Piney Grove Rd (SR1696) Latitude 36.138528 Longitude-80.069531
3. Approximate date land -disturbing activity will commence: April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Energy Infrastructure
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 '8
6. Amount of fee enclosed: $ 200 . The application fee of $100,00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been Fled? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Patrick Sizemore E-mail Address [e-mail]
Telephone [phone] Cell # 336-416-8632 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Utility Easement
Name Telephone Fax Number
Current Mailing Address
Current Street Address
City State Zip City
10. Deed Book No. N/A
Page No. N/A
State Zip
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.) It 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 Carolinas, LLC
Name
526 South Church Street
Current Mailing Address
Charlotte, NC 28202
City
State Zip
[e-mail]
E-mail Address
500 Utility Drive
Current Street Address
Clemmons, NC 27012
City State
Telephone [phone] Fax Number 336-917-2510
Zip

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 N/A Fax Number N/A
(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
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.
Patrick Sizemore Senior Engineering Technologist
Type or print name Title or Authority
_MJ;'Y _14 0 AyLer-zo
Signature 61 Date
I, fr��O r—, a Notary Public of the County of FO;—S
State of North o lina, hereby certify thatappeared
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A ipis day and being duly sworn acknowledged that the above form was
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