NCC241423_FRO Submitted_20240510

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 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 and/
or fax information unavailable, place N/A in the blank.)
P1.art AProject Name South Point Access Area - Phase 3
2. Location of land-disturbing activity: County Gaston City or Township Belmont
Highway/Street 199 Boat Launch RD Latitude 35° 9'30.69"N Longitude 81° 0'46.35"W
3. Approximate date land-disturbing activity will commence:May 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Access Area
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .42 Ac
6. Amount of fee enclosed: $ $200 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac= $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian Couture E-mail Address [e-mail]
Telephone [phone] Cell # 614-668-6191 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC 704-382-9257
Name Telephone Fax Number
525 S. Tryon Street - DEP 35B 525 S. Tryon Street - DEP 35B
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
10. Deed Book No. 1887 Page No.0546 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Duke Energy Carolinas, LLC [e-mail]
Name E-mail Address
525 S. Tryon Street - DEP 35B 525 S. Tryon Street - DEP 35B
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) if the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Karen Rozar [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake St., Ste 200 160 Mine Lake St., Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number
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
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 Person). I agree to provide
corr�ecte .nformation should there be any change in the information provided herein.
T e Title or Author
nature Date
I, wii £. LU. L , a Notary Public of the County o�
1
State of North Carolina, hereby certify that �u J. LLr appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my,q �i',l�ri4'ibt��ial seal, this I I day of , 20a4
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4., DUKE
ENERGY.
Memo to File:
Subject: Delegation of Signatory Responsibility for Water Permits; National Pollutant Discharge
Elimination System (NPDES), U.S.Army Corps of Engineers,and other Federal,State,
and/or Local Water Related Regulatory Programs
This correspondence serves as notification that I, Randy Herrin, as the Vice President of Carolinas
Regulated Renewables& Lake Services and acting as a responsible corporate officer hereby authorize
Eddie Duncan and Jeff Lineberger as duly authorized representatives to sign applications, reports, or
information on behalf of Duke Energy Carolinas, LLC and Duke Energy Progress, LLC with respect to
Federal, State, or Local program activities for project-related permit applications and certifications.
Randy H • Date
VP of Carolinas Reg Renewals& Lake Services