NCC242249_FRO Submitted_20240724

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.)
Part A. Stumpy Creek Access Area
1. Project Name
2. Location of land-disturbing activity: County Iredell City or Township
Stumpy Creek Road(SR 1301) 35.626453 -80.90'1992
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence:October 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Park
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):3:34
6. Amount of fee enclosed: $ $400.00 . 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 Ashlie Hood E-mail Address [e-mail]
Telephone [phone] Cell# 704-307-7880 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.968 Page No.247 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
corrected information should there be any change in the information provided/ herein.
Jeftr G lean G-1iC�ic r r Gr� (Jr r$t d ,Yr / ye to bit S`�` f ��k� SCE✓rC�J
Type or p nt name Title or Authority
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Signature Date
I, � re�.yn G. GOYV.c.-2 , a Notary Public of the County of k.tcACACn 6,4.3
State of North Carolina, hereby certify that 3 ce G-(en n 1-2i.ve bergs C appeared
personally before me this day and being duly sw6rn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this i 5 day of MaJ , 20 -0 -
EVELYN G. GOMEZ
NOTARY PUBLIC Notary
Scklenburg County North Carolina My commission expires Raj aj 'DO a 0 a
My Commission Expires May 20,2026