NCC222769_FRO Submitted_20220803

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Mayo -Person 500kV Line: Lattice Tower Replacement
2. Location of land -disturbing activity: County Person City or Township Roxboro
Highway/Street10660 Boston Rd. Latitude(dedmal degrees) 36.52260 Longitude(decimaldegrees) -78.9118'
3. Approximate date land -disturbing activity will commence: 08122
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 187 acres
6. Amount of fee enclosed: $ 18,700.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name NUwan Wijesuriya E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Utility Easement
Name
Current Mailing Address
City
10. Deed Book No.
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
State
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Duke Energy Progress, Li C (Attn: Nuwan Wjesuriya)
Company Name
410 South Wilmington Street NCO2
Current Mailing Address
Raleigh, NC 27601
[e-mail]
E-mail Address
410 South Wilmington Street NCO2
Current Street Address
Raleigh, NC 27601
City State Zip City State Zip
Phone: Office # [phone] Mobile # [phone]
!Vote: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
CT Corporation (Karen Rozar) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court, Suite 200 160 Mine Lake Court, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 Raleigh NC 27615-6417
City State Zip City State Zip
Phone: office # 919-844-8360 Mobile #
Karen Rozar
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Offce # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) if the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Nuwan Wijesulriya
Lead Transmission Permitting Manager
Type or print name Title or Zvo'li
Signature Date
I , SGl f- L1F_'/►''i a Notary Public of the County of 1 u ee
State of North Carolina, hereby certify that Nuvnn t1 i''PSOL appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this _day of�e
2 .c
:m
��� y • oa�,pn 2 : y, �.
i F COON
20
Notary --
My commission expires