NCC231944_FRO Submitted_20230623

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 N/A in the blank.)
Part A.
1. Project Name Hibernian — Construct New 230kV Tap Line
2. Location of land-disturbing activity: County Chatham City or Township Slier City
Highway/Street JC Teague Road Latitude degrees) 35.7488 -79.5449
Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence. July 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Infrastructure
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 23.76
6. Amount of fee enclosed $2000 + $2400 The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre(rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Nuwan Wijesuriya E-mail Address [e-mail]
Phone: Office# 919.546.2090 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners)
DUKE ENERGY PROGRESS, LLC 919.546.6111 N/A
Name Phone: Office# Mobile#
410 S. WILMINGTON ST. 410 S. WILMINGTON ST.
Current Mailing Address Current Street Address
RALEIGH, NC. 27601 RALEIGH, NC. 27601
City State Zip City State Zip
10. Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.

Part B.
I. 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 individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(ies).
DUKE ENERGY PROGRESS, LLC. [e-mail]
Company Name E-mail Address
410 S. WILMINGTON ST. 410 S. WILMINGTON ST.
Current Mailing Address Current Street Address
RALEIGH, NC. 27601 RALEIGH, NC. 27601
City State Zip City State Zip
Phone: Office# 919.546.2090 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 SYSTEM [e-mail]
Name of Registered Agent E-mail Address
160 MINE LAKE CT., SUITE 200 160 MINE LAKE CT., SUITE 200
Current Mailing Address Current Street Address
RALEIGH, NC. 27615 RALEIGH, NC. 27615
City State Zip City State Zip
Phone: Office#919.844.8360 Mobile# N/A
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)
(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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
McAdams [e-mail]
Engineering firm or other consultant E-mail Address
Claudia Prado, PE. 919.361 .5000 704.650.2984
Individual contact person (type or print) Phone: Office# Mobile#
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.
Nuwan Wijesuriya Lead Transmission Permitting Manager
Type or print na
mTitle or Authority
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Signature V Date
I, 4<acatu"\Ja., 4. k'YU , a Notary Public of the County of Wai<C.-
State of North Carolina, hereby certify that NU n W t)es wig appeared personally
before me this day and being duly sworn acknowledged that the abode form was executed by him/her.
Witness my hand and notarial seal, this 1?� day of (U. lc' . 20d3
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I I J MCADAMS
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THE JOHN R.MCADAMS COMPANY,INC
621 HILLSBOROUGH ST STE 500 66-46/531
RALEIGH,NC 27603 CHECK DATE
[phone] June 8, 2023 2
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PAY Two Thousand Four Hundred and 00/100 Dollars
AMOU T 2,400.00 N
TO NCDEQ I
VOID • 180 DAYS n
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AUTHORIZED SIGNATURE I

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la MCADAMS
TR U I ST p ki.�,:%.>
j THE JOHN R.MCADAMS COMPANY,INC
621 HILLSBOROUGH ST STE 500 66-46/531
1 RALEIGH,NC 27603 CHECK DATE
[phone] June 8,2023
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PAY Two Thousand and 00/100 Dollars 11
AMOUNT 2,000.00 ,,,
TO NCDEQ VOID :0 DAYS 8
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11 ti, l.,, II
AUTHORIZED SIGNATURE