NCC230242_FRO Submitted_20230127

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 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 [e-mail]
Mobile # [phone]
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
[e-mail]
E-mail Address
500 Utility Drive
Current Street Address
Clemmons, NC 27012
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)
Name of Registered Agent
160 Mine Lake Court, Suite 200
[e-mail]
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.