NCC215664_FRO Submitted_20211013

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. Powhatan Industrial 230kV Substation Expansion
1. Project Name
2. Location of land -disturbing activity: CountyWake 3Q44 Cityen or TownshipClayton
Highway/Street 3612 Powhatan Rd Latitude 35.619 Longitude—78.408
3. Approximate date land -disturbing activity will commence: 11/1/21
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Industrial (elecMcal substaiton)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 3.1
6. Amount of fee enclosed. 3 1 , 260 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes.-_-_ No Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Reuben Jones E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Progress, LLC 919-546-2235 919-546-7175
Name Telephone Fax Number
410 South Wilmington Street 550 South Tryon Street, DEC 45A
Current Mailing Address Current Street Address
Raleigh NC 27601 Charlotte NC 28202
City State Zip City State Zip
10. Deed Book No. 1491 Page No. 096 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 Progress, LLC [e-mail]
Name E-mail Address
410 South Wilmington Street 410 South Wilmington Street
Current Mailing Address Current Street Address
Raleigh NC 27601 Raleigh NC 27601
City State Zip City State Zip
Telephone [phone] Fax Number 919-546-7175

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
CT Corporation System (Karen Rozar) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct., Ste 200 160 Mine Lake Ct., Ste 200
Current Mailing Address
Raleigh NC 27615
City State
Telephone [phone]
Zip
Current Street Address
Raleigh NC 27615
City State Zip
Fax Number
(c) In 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:
McAdams [e-mail]
Engineering Firm or other consultant E-mail Address
Patrick Covil 919-633-3806
Individual contact person (type or print) Telephone 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.
Alan Lewis Manager, Transmission_ Engineering
Type or r�nt na Title or Authority
Of- 0 ad��
S i g ri-afure Date
�ja Notary Public of the County of. t'�
State of North Carolina, hereby certify thi ,, 1 (['I �Q,�}S.] appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hfflOj4t[4,qotarial seal, this day of 20
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My commission expires_
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