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HomeMy WebLinkAboutNCC241633_FRO Submitted_20240607 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 Dunns mountain Retail Substation Design 2. Location of land-disturbing activity: County Rowan City or Township Salisbury Highway/Street Dunns Mountain Road Latitude(decimai degrees) 35.628611° -80.426697° Longitude(decimal degrees) 3. Approximate date land-disturbing activity will commence: Summer 2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.56 acres 6. Amount of fee enclosed $2,100.00 . 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 El Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Brandon Lewis E-mail Address Brandon.Lewis2@duke-energy.com Phone: Office# 704-382-9978 Mobile# 704-674-4536 9. Landowner(s) of Record (attach accompanied page to list additional owners): Duke Energy Carolina, LLC Name Phone: Office# Mobile# 400 South Tryon Street, Suite 30C 400 South Tryon Street, Suite 30C Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip 10. Deed Book No.554/621 Page No.551/775 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 Carolina, LLC Company Name E-mail Address 400 South Tryon Street, Suite 30C 400 South Tryon Street, Suite 30C Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip Phone: Office# Mobile# 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 SouthTeam2@wolterskluwer.com Name of Registered Agent E-mail Address 160 Mine Lake Ct, Ste 200 160 Mine Lake Ct, Ste 200 Current Mailing Address Current Street Address Raleigh NC 27615 Raleigh NC 27615 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 & Infrastructure Inc Richard.Hiner@wsp.com Engineering firm or other consultant E-mail Address Richard L Hiner 704-357-5599 704-533-3630 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. Darrin Cardwell Manager, Substation Engineering Carolinas West Type or print name Title or Authority 6130 Signature Date Brandon Lewis , a Notary Public of the County of Mecklenburg State of North Carolina, hereby certify that Darrin Cardwell 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 3oT" day of IvUE , 20 23 BRANDON LEWIS Notary Public- North Carolina D Mecklenburg County �E� IhYk�YYI �O�A.0.4 BRpNDON LFbJ IS My Commission Expires Jun 11, 2024 ( Notary !/ Seal My commission expires JI NE II, 2024- 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 r City State Zip City t, " 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.