NCC240944_FRO Submitted_20240402

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 Roxboro Industrial Landfill Expansion E&SC Plan Modification 2
2. Location of land-disturbing activity: County Person City or Township Semora
Highway/Street 1700 Dunnaway Rd Latitude(decimal degrees) 36.47828 Longitude(decimal degrees) -79.05719
3. Approximate date land-disturbing activity will commence: Spring 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
Additional-14,5 ac Total-180.78 ac
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed s1500•:2.000ta.P,sssl-:3.500 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 NCDEO.
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 Issa Zarzar E-mail Address [e-mail]
Phone: Office# 919-546-7574 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Duke Energy Progress, LLC 800-777-9898 N/A
Name Phone: Office# Mobile#
PO Box 1551-PEB3A 1700 Dunnaway Rd
Current Mailing Address Current Street Address
Raleigh NC 27602 Semora NC 27343
City State Zip City State Zip
10. Deed Book No. 98 and others Page No.267 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 individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Duke Energy Progress, LLC(Attn lssa Zarzar) [e-mail]
Company Name E-mail Address
PO Box 1551 - PEB3A PO BOx 1551 - PEB3A
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27602
City State Zip City State Zip
Phone: Office# 919-546-7574 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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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 N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office # N/A Mobile# N/A
N/A
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.
N/A
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:
WSP USA Environment and Infrastructure Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Thomas Maier 704-417-5306 704-898-4410
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.
Issa J. Zarzar GM CCP Project Management
Type or print name Title or Authority ,J
3/2c / .2 0
Signature Date
I, 11 1 1 1213 h O Ala Notary Public of the County of M e if 0\
State of North Carolina, hereby certify that l S.ci J. 2curzcur 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 Z.0 day of , 20 3-1-1
,.�'�.{ R06,� ,, , Notary
•s " expiresc� �I� () Ito
o TA,r Y, My commission
U PuBoo
0

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:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Landowner 3 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Landowner 4 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Landowner 5 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No.N/A 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.
N/A N/A
Company 2 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 3 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 4 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 5 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A