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HomeMy WebLinkAboutNCC230242_FRO Submitted_20230127FINANCIAL 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 address or phone number is unavailable, place NIA in the blank.) Part A. 1. Project Name U-5760 Big Mill Farm 1 Hopkins Road Widening Part 1 2. Location of land -disturbing activity: County Forsyth City or Township Kernersville Hopkins Road ! Big Mill Farts Rd 36,121435-80.107648 Highway/Street Latitude{deamei deQrtres) Longitude(decimal dagrees). 3. Approximate date land -disturbing activity will commence: August 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Electric Infrastructure 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.5 6. Amount of fee enclosed: $ 700 . 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 $900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Patrick Sizemore Phone: Office # 336-917-2522 E-mail Address Patdck.Sizemore@duke-energy.com Mobile # 336-416-8632 9. Landowner(s) of Record (attach accompanied page to list additional owners): Utility Easement Name Current Mailing Address City State Zip 10. Deed Book No. Page No Phone: Office # Mobile # Current Street Address City State Zip Provide a copy of the most current deed. (c) If the Financially Responsible Party is engaging in business under an assumed name, give name under which the company is Doing Business As. If the Financially Responsible Party is an individual, General Partnership, or other company not registered and doing business under an assumed name, attach a copy of the Certificate of Assumed Name. Company DBA Name The above information is true and correct to the best of my knowledge and belief and was provided by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s) or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with the authority to execute instruments for the Financially Responsible Party). I agree to provide corrected information should there be any change in the information provided herein. Patrick Sizemore Type or print name Signature Senior Engineering Technologist Title or Authority Date I, �jk Me1 5 , a Notary Public of the County of fCor'sX'f State of North Carolina, hereby certify that A4-p c k S; zemom appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/her. Witness my hand and notarial seal, this day of Qc4be(` , 20-&a No ary F6cNOTARYPUBLIC BS MERE$ My commission expires QG)d%er oZ, Das syth County rth CaroNna n Expires Oct.12, 2MS 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 Iandowner(s) is an individual(s), the name(s) of the owners) may be listed as the financially responsible party(ies). Duke Energy Progress, LLC Company Name 526 South Church Street Current Mailing Address Charlotte, NC 28202 City State Zip Phone: Office # 336-917-2522 Patrick.Sizemore@duke-energy.com E-mail Address 500 Utility Drive Current Street Address Clemmons, NC 27012 City State Zip Mobile # 336-917-2522 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) Name of Registered Agent 160 Mine Lake Court, Suite 200 ct-statecommunications@wolterskluwer.com E-mail Address 160 Mine Lake Court, Suite 200 Current Mailing Address Current Street Address Raleigh INC 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: 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) Continued from Item 1 in Part B 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 Name 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 Zip City State Zip Phone: Office # Mobile # Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Continued from Items 9 & 90 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: Name Phone: Office # Mobile # 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 3 of Record: Name Phone: Office # Mobile # Current Street Address Current Mailing Address City State City State Zip Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State City State Zip Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 5 of Record: Name Phone: Office # Mobile # 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.