NCC220907_FRO Submitted_20220228

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. Southern Pines Center Park 115kV Substation
1. Project Name
2. Location of land -disturbing activity: County Moore City or Township Southern Pines
Highway/Street US 15-501 Hwy Latitude 35.166833 Longitude-79.422639
3. Approximate date land -disturbing activity will commence: April 4, 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): 8.03
6. Amount of fee enclosed: $2,900.00 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Josh Witherspoon E-mail Address [e-mail]
Telephone [phone] cell # 919-219-9549 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Carolina Power & Light Co. D.B.A Duke Energy Carolinas 919-546-2177
Name Telephone Fax Number
P.O. Box 1551 410 S. Wilmington Street
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27601
City State Zip City State Zip
10. Deed Book No. 401 Page No. 219 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
410 S. Wilmington Street
Current Mailing Address
Raleigh NC 27601
City
E-mail Address
410 S. Wilmington Street
Current Street Address
Raleigh NC 27601
State Zip City
State
Zip
Telephone [phone] 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
Telephone
State Zip
E-mail Address
Current Street Address
City State Zip
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 (Karen Rozar)
Name of Registered Agent
160 Mine Lake Court, Suite 200
Current Mailing Address
Raleigh NC
City
State
Telephone [phone]
27615-6417
Zip
[e-mail]
E-mail Address
160 Mine Lake Court, Suite 200
Current Street Address
Raleigh
City
Fax Number
NC 27615-6417
State Zip
(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:
Dewberry Engineering
[e-mail]
Engineering Firm or other consultant E-mail Address
Fred Rash 919-424-3748
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.
Josh Witherspoon
Senior Transmission Permitting Manager
Type or print name Title or Au ority
Sigkfure Date
►, �,��i�/k€LJ C✓� v.S' a Notary Public of the County of
State of North Carolina, hereby certify that S' f' �` �`` "� (; , k �s�} �'� appeared personally
before me this day and being duly sworn acknowledged that the alsove form w s executed by him.
Witnelitlln arial seal, this jj_day of c!� C �^ 20
Notary
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My commission expires
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