NCC221587_FRO Submitted_20220425

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. Wilkes Tie
1. Project Name
2. Location of land -disturbing activity: CountyWllkes City or TownshipWllkesboro
Highway/Street RIVer rd Latitude 36010' 37.9N Longitude 8106' 37.36W
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Transmission
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 25.2
6. Amount of fee enclosed: $ 2,600 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eric Shook E-mail Address [e-mail]
Telephone cell # 336-416-9168 Fax #
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
526 South Church Street, EC09Q 526 South Church Street, EC09Q
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
526 South Church Street, EC090
Current Mailing Address Current Street Address
Charlotte NC 28202
City
State Zip City
Telephone [phone] Fax Number.
State
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:
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 Lander an
assumed name, attach a copy:of the Cartiiicate of Assumed Name, If the Financially Responsible
Party is a Corporation, give name and street address of the Registered. Agent:
C T Corporation System clo Karen Rozar [e-mail]
Name of Registered Agent E-mail Address
160 Mine. Lake Ct,, Suite 200
Current.Maiiing Address Current Street Address
Raleigh NC 2761 5-6417
City State Zip City State Zip`
Telephone [phone] 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 Veltri. Director; Transmission Permitting
1,Ype r pri name I Title or Authority
Oign Lure Date
a Notary Public of the County of { n, l on
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of 01-' 7 k) , ZQ L 2.
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