NCC230467_FRO Submitted_20230216

FINANCIAL RESPONSIBILITYIOWNERSHIP 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.G. 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 N,A in the blank.)
Part a
1. Project Name Delta 100kV Transmission Line
2. Location of land -disturbing activity: County Durham City or Township NIA
Durham Fw S 35.94442 -78.86723
Highway: Street � Latitude(decima� degrees} Longi�Fudetaed� ass}
1 Approximate date land -disturbing activity will commence: March 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial (Transmission)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.12
6. Amount of fee enclosed: $ 1,700.00 . 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 ❑x No RI
8. Person to contact should erosion and sediment control issues arlse during land -disturbing activity-
Name3effrey Goto E-mail [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowners) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC [phone] NIA
Name Phone: Office 9 Mobile #
526 South Church Street EC109Q 526 South Church Street EC1090
Current Mailing Address Current Street Address
Charlotte NC 28202-1802 Charlotte NC 28202-1802
City State Zip City State Zip
10. Deed Book No. NIA Page No. N/A 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 or if the landowner(s) is
an individuals}, the names) of the owner(s) may be listed as the financially responsible party(ies).
Duke Energy Carolinas, LLC [e-mail]
Company Name E-mail Address
526 South Church Street EC109Q 526 South Church Street EC109Q
Current Mailing Address Current Street Address
Charlotte NC 28202-1802 Charlotte NC 28202-1802
City State Zip city State Zip
Phone: Office # [phone] Mobile # NIA
Nate: 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 Systems CIO Karen Rozar
Name of Registered Agent
160 Mine Lake Ct. Suite 200
Current Mailing Address
Raleigh NC 27615-6417
ct-statecommunicationsCo wolterskiuwer.com
E-mail Address
NIA
Current Street Address
NIA
City State Zip City State Zip
Phone: Office # [phone] Mobile # NIA
Jeffrey Goto, PE
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 --
N/A NIA
Name of Registered Agent E-mail Address
NIA NIA
Cuffent Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
Phone: office # NIA
NIA
Mobile; NIA
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 aBA 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). l agree to provide
corrected information should there be any change in the information provided herein,
Jeffrey Goto
Type or print name
/..:�
Sigr(aturer
Lead Transmission Permitting Manager
Title or Authority
w-bD/aO22
Date
In me-(tn�O `i -?iqer �f , a Notary Public of the County of
State of North Carolina, hereby certify that J&I�rre-(-/ 47D'7z appeared personally
before me this day and being duly sworn acknowiedged that the ahove form was executed b�her.
Witness my hand and notarial seal, this ado day of ��C�mxet— , 20 a�-
., 9, n'WA
`.`��.' ONGF� Notary
-_j�� My commission expires /t 3- a13 6o
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