NCC221515_FRO Submitted_20220420

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. Roxboro Borrow Area 8 Plan
1. Project Name
2. Location of land -disturbing activity: County Person City or Township Semora
Highway/Street Dunnaway Rd Latitude 36.484682 Longitude -79.058439
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): 83.0 Acres
6. Amount of fee enclosed: $ 83 x $100 = $8,300 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 filed? Yes NSA No NSA Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Duncan Brewer E-mail Address [e-mail]
Telephone [phone] Cell # 336-330-2058 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Progress, LLC
[phone] 919-546-7175
Name
Telephone Fax Number
PO Box 1551-PEB3A
1700 Dunnaway Rd
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 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 maybe listed as the financially responsible party.
Duke Energy Progress, LLC
[e-mail]
Name
E-mail Address
1700 Dunnaway Road
1700 Dunnaway Road
Current Mailing Address
Current Street Address
Semora NC 27343
Semora NC 27343
City State Zip
City State " Zip
336-330-2058
91 g-546-7175
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:
N/A N/A
Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A N/A
N/A N/A N/A N/A
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:
N/A
N/A
Name of Registered Agent
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A N/A
N/A N/A N/A N/A
City State
Zip City State Zip
N/A
Fax Number N/A
Telephone,
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.
�C Vl Cct vt D ce-Lez-/ 6 fU L' Ct Ye C( c -r
Type or riot name Title or Authority
Si nature Date
I, )�qe'i f (/v( GC n/i , a Notary Public of the County of IN a JQ
State of North Carolina, hereby certify that H JL'-'/ I 01(A n P r-e'"le-appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
tLWitness my hand and notarial seal, this day of /A `�,oC � , 20 a
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_ �, Notary
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My commission expires