NCC223710_FRO Submitted_20221031

NC Department of
Environmental Quality
Received
GUI L r - Zcq OCT 21 2021
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT Winston-Salem
Regional Ofhi e
No person may initiate any land -disturbing activity on one or more acres as covered by the Act be ore hcis
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. U-6018 WO# 36103560
1. Project Name
2. Location ofland-disturbing activity: County Guilford City or Township High Point
Highway/Street N.C. 62 (Liberty Road) Latitude 35.923323 Longitude-79.939691
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Energy Infrastructure
S. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.99
6. Amount of fee enclosed: $ 455 . 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 Patrick Sizemore
E-mail Address [e-mail]
336-917-2522
Cell # 336-416-8632 Fax # [phone]
Telephone
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Utility Easement
Name
Telephone Fax Number
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) 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
500 Utility Drive
Current Mailing Address
Current Street Address
Charlotte, NC 28202
Clemmons, NC 27012
City State
Zip City State Zip
336-917-2522
336-917-2510
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. -
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 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..
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
Fax Number
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.
Patrick Sizemore Senior Engineering Technologist
Type or print name
Title or Authority
Patrick Sizemore Digitally signed by Patrick Sizemore ��/
Date: 2021.10.11 14:05:30-04'00'16 /
Signature Date I
I, c-, 4-1 i c w_ a Notary Public of the County of
r'
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
execute�c��br%Mry
"MO
O
Win •,,And nd��' ial seal, this _day of ICJ 20 a�
1 o J O=
Vn
C�
02-Z Notary
0 $mial -� s
�Q� ems`' My commission expires tk St j5 DCa�