NCC216537_FRO Submitted_20211122

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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A. Wittenberg Access Area
I . Project Name
2. Location of land -disturbing activity: County Alexander City or Township Hickory
Highway/Street 175 Wildlife Access Road Latitude 35048'20.65" N Longitude 81 °18'45.66" W
3. Approximate date land -disturbing activity will commence: November, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public Water Access
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8'58
6. Amount of fee enclosed: $ $2'585 . 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ryan Snitker E-mail Address [e-mail]
Telephone [phone] Cell # 703-935-6271 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Power Company 704-382-8849
Name Telephone Fax Number
PO Box 1007 NIA
Current Mailing Address Current Street Address
Charlotte NC 28201 N/A
City State Zip City State Zip
10. Deed Book No. 364 Page No. 2304 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Duke Energy Carolinas, LLC [e-mail]
Name E-mail Address
526 S. Church Street, EC12Q 526 S. Church Street, EC12Q
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
Telephone [phone] Fax Number NIA

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:
NIA NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
N/A
NIA
City State Zip
City State Zip
Telephone NIA
Fax Number NIA
(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; Attn: Karen Rozar
[e-mail]
Name of Registered Agent
E-mail Address
160 Mine Lake Ct, Suite 200
N/A
Current Mailing Address
Current Street Address
Raleigh, NC 27615-6417
NIA
City State Zip
City State Zip
Telephone [phone]
Fax Number NIA
(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:
Wood Environment & Infrastructure Solutions,
[e-mail]
Engineering Firm or other consultant
E-mail Address
Richard L Winer, PE, CPESC
704-533-3630 NIA
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.
t
Type or print name
Signatu
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Title or Authority
Date
I, VAYOW 0 . lky , a Notary Public of the County of W IMk
State of North Carolina, hereby certify that � 'MIL _ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my han,�l tngjarial seal, this day of h1N 20'M
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My commission expires OWN Lolu
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