NCC222764_FRO Submitted_20220803

FINANCIAL RESPONSIBILITWOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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: Laydown Area
2. Location of land -disturbing activity: County Person City or Township Woodsdale
Highway/Street Woody's Store Rd Latitude(decimal degrees) 36.52673 Longitude (decimal degrees) -778.93892
3. Approximate date land -disturbing activity will commence: 08/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15 acres
6. Amount of fee. enclosed $3,500.00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 peracre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed N No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nuwan Wljesuriya 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
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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 orif 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, LLC (Attn: Nuwan WIlesuriya)
Company Name
410 South Wilmington Street
Current Mailing Address
Raleigh, NC 27601
City State Zip
Phone: Office # [phone]
nuwan.wijesuriya@duke-�energy.com
E-mail Address
410 South Wilmington Street
Current Street Address
Raleigh, NC 27601
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's 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: Office # 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 RBA Name
(d) If 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:
Wood E&IS
Engineering firm or other consultant
Claudia Prado
Individual contact person (type or print)
[e-mail]
E-mail Address
[phone]
Phone: Office # Mobile #
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 Wijesuriya
Type or print name
Signature
Lead Transmission Permitting Manager
Title or Authority
Date
I, D&41�- 6WA ht , a Notary Public of the County of %Vices
State of North Carolina, hereby certify that 1AVIN404 W UESUPIMA _ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and no%ial seal, this
�®gaatiti
�� �. �;�ssionF•. v
o;�=OJAR
y
day of Ja 9VL020 22
Notary
My commission expires Ile ag Xr

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Malls AGRI Business, LLC. [phone]
Name Phone: Office #
705 Berryhill Road
Current Mailing Address Current Street Address
Roxboro NC 27574
City State Zip City State Zip
Deed Book No. 341 Page No, 639 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office #
Current Mailing Address Current Street Address
Mobile #
Mobile #
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office #
Current Mailing Address Current Street Address
City
Deed Book No
State Zip City
Page No.
Mobile #
State zip
Provide a copy of the most current deed.

Continued from Item 9 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 dame E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Phone: Office #
Zip City State
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Phone: Office #
Zip City State
Mobile #
Zip
Zip