NCC241119_FRO Submitted_20240415

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Buck Main and Additional Soil Stockpile Erosion and Sediment Control Plan
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Rowan City or Township Salisbury
Dukeville Road 35.7031 -80.3672
Highway/Street LatltUde(decnaldegrees) Longltudeoecimaldegrees)
3. Approximate date land-disturbing activity will commence: 4/1/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10.5
6. Amount of fee enclosed: $$1,100= 11 ac x$100/ac 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 Ill No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dale Wooten E-mail Address [e-mail]
Phone: Office# 704-630-3086 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC (Attn: lssa Zarzar) 919-546-7574 919-812-0446
Name Phone: Office# Mobile#
411 Fayetteville St NC03 1555 Dukeville Road
Current Mailing Address Current Street Address
Raleigh NC 27601 Salisbury NC 28146
City State Zip City State Zip
10. Deed Book No. 1 81/421 Page No.407/550,544 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 Carolinas, LLC (Attn: Issa Zarzar) [e-mail]
Company Name E-mail Address
411 Fayetteville St NC03 1555 Dukeville Road
Current Mailing Address Current Street Address
Raleigh NC 27601 Salisbury NC 28146
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:
CT Corporation [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court, Suite 200 160 Mine Lake Court, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office# 919-944-8360 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:
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
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 General Manager, CCP Project Management
Type or print name Title or Authority
-2/21"/2 v z /
Signature Date
I, holly Ake-Mann , a Notary Public of the County of arSoel
State of North Carolina, hereby certify that S CA. Zar 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 '2 A day of Feb rvek. , 20 A.'1
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My commission expires 16/30/-24
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DA2157
19
400E ENERGY STREEINAS, LLC cirso DUKE
400 S TRYON STREET
ACCOUNTS PAYABLE - ST25B E N E RGY. Page 1 of 1
CHARLOTTE, NC 28202
Date: 03/04/2024
Check#: 1000205092
000010 R3K1SDA Payment Amount: 1,100.00
NORTH CAROLINA DEPARTMENT OF Vendor#: 0000071949
,P �; ENVIRONMENTAL QUALITY
MOORESVILLE REGIONAL OFFICE
610 EAST CENTER AVE SUITE 301
MOORESVILLE NC 28115
Remittance Advice
Invoice Date Invoice# Voucher ID# Invoice Gross Amt Discount Amount Invoice Net Amt

PLEASE DETACH BEFORE DEPOSITING CHECK
THIS CHECK CONTAINS MULTIPLE FRAUD DETERRENT SECURITY FEATURES
400E ENERGY TREEINAS, LLC S DUKE
400 5 TRYON STREET � /�'yii ENERGY®
ENERV
ACCOUNTS PAYABLE - ST25B � Date: 03/04/2024
CHARLOTTE, NC, 28202 Check#: 1000205092
Pay Exactly **One Thousand One Hundred and 00/100-US Dollars** Amount z
$****1,100.00
TO THE NORTH CAROLINA DEPARTMENT OF 8
ORDER ENVIRONMENTAL QUALITY VOID AFTER180DAYS
OF
#W--+==>
JP MORGAN CHASE BANK, N.A. A thorized signer
SYRACUSE,NY 13206