NCC191758_NOT Closeout Documents (3)_20230124

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 Environment and Natural Resources. (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.
1. Project Name Burnsville Substation (AMENDMENT)
2.
Location of land -disturbing activity: County Anson City or Township Polkton
Highway/Street Race Track Rd. Latitude 35.112420 Longitude-80.244420
3.
Approximate date land -disturbing activity will commence: September 30, 2018
4.
Purpose of development (residential, commercial, industrial, institutional, etc.): Electric substation
5.57 (original) + 0.99
5.
Total acreage disturbed or uncovered (including off -site borrow and waste areas)(new) = s.5s acres
$65.00 (other $390.00
6.
Amount of fee enclosed: $ Previously Paid) 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).
NOTE: ESC Plan
7.
Has an erosion and sediment control plan been filed? Yes `" No Enclosed
and drawings have
already been filed.
The nev drawing5
showing the
8.
Person to contact should erosion and sediment control issues arise duringland-disturbing activity
9 `7 •
addafes are
enclosed hero
enclosed here
Name Briana D. Eddy E-mail Address [e-mail]
Telephone [phone] x188 Cell # 919-218-1652 Fax # [phone]
9.
Landowner(s) of Record (attach accompanied page to list additional owners):
Pee Dee Electric Membership Corporation 704-694-2114
Name Telephone Fax Number
575 US-52 575 US-52
Current Mailing Address Current Street Address
Wadesboro NC 28170 Wadesboro NC 28170
City State Zip City State Zip
10.
Deed Book No. 1190 Page No. 146 - 148 Provide a copy of the most current deed.
Part B.
t. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Pee Dee Electric Membership Corporation teason(aD-pdemc.com Tony Eason, Dir. of E&O
Name
575 US-52
E-mail Address
575 US-52
Current Mailing Address Current Street Address
Wadesboro NC 28170 Wadesboro NC 28170
City State
Telephone [phone]
Zip City State Zip
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:
I/VI
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:
N/A
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.
Anthony E Eason
Director of Engineering & Operations, Pee Dee Elec.
Type or print nam Title or Authority
Signatur Date
------------ ----------------- __—--------- _---------------------------------------------------------------------------------------
I Ab G- f J e�A-oV­11 , a Notary Public of the County of PC ; 0n
State of North Carolina, hereby certify that E- r- a 5 0 -, . appeared
personally before me this day and being duly swornJ acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 4�� day of ALpk-cuvtb-cr , 20 11
u C '❑
i. _xs,kS
Notary
Seal
My commission expires

Additional Landowners
1. Landowner(s) of Record
David W. Sr. & Catherine S. Frailey
Name
2370 Race Track Road
Telephone
Current Mailing Address Current Street Address
Polkton NC 28135
Fax Number
City State
Zip City
State Zip
Deed Book No, 1145
Page No.141
Provide a copy of the most current deed.
2. Landowner(s) of Record
Duke Energy Progress, LLC
Name
Telephone
Fax Number
400 S Tryon Street
Current Mailing Address
Current Street
Address
Charlotte NC
28201
City State
Zip City
State Zip
Deed Book No. 149
Page No. 270
Provide a copy of the most current deed
3. Landowner(s) of Record
Joshua B. Bowers
Name
Telephone
Fax Number
2569 Race Track Road
Current Mailing Address
Current Street Address
Polkton NC
28135
City State
Zip City
State Zip
Deed Book No. 959
Page No. 265
Provide a copy of the most current deed.