NCC221044_FRO Submitted_20220315

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 N/A in the blank.)
Part A. Hankins 44kV Line Rebuild Phase 2
1. Project Name
2. Location of land -disturbing activity: County McDowell City or Township Marlon
Highway/Street U.S. Highway 70 Latitude 35.7020740 Longitude-81.9673900
3. Approximate date land -disturbing activity will commence: September 1 , 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Transmission Line Rebuild
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 41.8
6. Amount of fee enclosed: $ 2,730 . 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 Neal Cary
E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC
704-382-2741 n/a
Name
Telephone Fax Number
550 S Tryon St, Ste 4500
526 South Church Street
Current Mailing Address
Current Street Address
Charlotte NC 28202
Charlotte NC 28202
City State Zip
City State Zip
10. Deed Book No. N/A Page No.
N/A 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 Carolinas, LLC
[e-mail]
Name
E-mail Address
550 S Tryon St, Ste 4500
526 South Church Street
Current Mailing Address
Current Street Address
Charlotte NC 28202
Charlotte NC 28202
City State Zip
City State Zip
Telephone [phone]
Fax Number 704-382-6542

2. (a) If the Financially Responsible Party is nota resident of North Carolina, give name and street address
of the designated North Carolina Agent:
N/A
Name
Current Mailing Address
City
Telephone
E-mall Address
Current Street Address
State 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
Panty is a Corporation, give name and street address of the Registered Agent:
CT Corporation
Name of Registered Agent
160 Mine Lake Court, STE 200
Current Mailing Address
Raleigh NC 27615
E-mail Address
N/A
Current Street Address
N/A
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.
Randy N, Veltri
Type or print name
Director, Transmission Permitting
Title or Authority
-b,Zi-, 2-'1
Date
I; .......... 7. .Z `_r S , a Notary Publ' .of the County of
State of North Carolina; hereby certify that _I SI_14 (-alto L, C11__ appeared
personally before me this day and being limy swornacknowledged that the above form was
executed by him.
f
Witness my hand and notarial seal, this,.day of l T , 20 , a-____,__�
=County,North
Public
inallotary.
My commission expires