NCC233124_FRO Submitted_20231019

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 Cowans Ford Access Road
2 Location of land-disturbing activity: County Lincoln City or Township Stanley
Highway/Street251 Duke Lane Latitude,,edma degrees) 35.433 Longitude,,a c,nzdegrees) -80.963
3 Approximate date land-disturbing activity will commence:As soon as possible
4 Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas). 6
6 Amount of fee enclosed 2,100 . 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 Kyle Norcross E-mail Address [e-mail]
Phone: Office# 828-735-0954 Mobile#
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC
Name Phone: Office# Mobile#
257 Duke Lane 257 Duke Lane
Current Mailing Address Current Street Address
Stanley NC 28164 Stanley NC 28164
City State Zip City State Zip
10 Deed Book No.393 Page No 297 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 inclividual(s) the name(s) of the owner(s)may be listed as the financially responsible party(ics)
Duke Energy Carolinas, LLC [e-mail]
Company Name E-mail Address
257 Duke Lane
Current Mailing Address Current Street Address
Stanley NC 28164
City State Zip City State Zip
Phone: Office# 704 998-7845 Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landoviner'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
60 Mine Lake Ct Ste 200 60 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State City State
Phone: Office# 919-546-7111 Mobile#
John Weber
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
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:
CESO, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Corey Clark 803-730-4057
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.
i vocz ¶ iu2r K- 6-r1 cD 5AST EP.M-447-9
Type or print name Title or Authority
ignature Date
I, e4Liwy, ,B. Ldiuz, , a Notary Public of the County o car--
State of North Carolina, hereby certify thatJjtcyPt.. ,$. 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 , 203
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Notary
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Continued from Items 9 & 10 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 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 4 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 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.

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#

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
D ) NOT MAIL THIS FORM OR PAYMENT UNTIL Y OUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL. SIGNATURE (NOT DIGITAL) 140 CFR 122,221
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article . . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of lab/. I certify that (check all boxes to indicate your agreement):
❑� I am the person responsible for the construction activities of this project, for satisfyln, the requirements of this
permit. and for any civil or criminal penalties incurred due to violations Of this permit.
The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based, on my inquiry of the person or persons who manage the system, or those persons directly responsible for
at'hei ing the information.
I v ii) abide by all conditions of the NCGO10000. OenaraL_f'erinit and the approved Erosion and Sediment Control
n
Pla
loll
Q IF the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times
Q I hereby request coverage under the NCG01000U General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): Cowans Ford Access Road
Specific Lot Numbers (must match Alb):
Permittee (must match 81): Duke Energy Carolinas, LLC
Legally Responsible Person (must match 82& 83): Trevor Turner
Title of Legally Responsible Person (must match 83b): General Manager II
Print Name &Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number:
Signature of Legally Responsible Person or Authorized Individual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,Section B,
Item (6)of the NCG010000 permit.