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HomeMy WebLinkAboutNCC216845_FRO Submitted_20211210NC Department of Environmental Quality Received GUI L r - Zcq OCT 21 2021 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT Winston-Salem Regional Ofhi e No person may initiate any land -disturbing activity on one or more acres as covered by the Act be ore hcis 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. U-6018 WO# 36103560 1. Project Name 2. Location ofland-disturbing activity: County Guilford City or Township High Point Highway/Street N.C. 62 (Liberty Road) Latitude 35.923323 Longitude-79.939691 3. Approximate date land -disturbing activity will commence: 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Energy Infrastructure S. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.99 6. Amount of fee enclosed: $ 455 . The application fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585). 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 Patrick Sizemore E-mail Address Patrick.Sizemore@duke-energy.com 336-917-2522 Cell # 336-416-8632 Fax # 336-917-2510 Telephone 9. Landowner(s) of Record (attach accompanied page to list additional owners): Utility Easement Name Telephone Fax Number Current Mailing Address Current Street Address City State Zip City State Zip 10. Deed Book No. Page No. 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 Patrick.Sizemore@duke-energy.com Name E-mail Address 526 South Church Street 500 Utility Drive Current Mailing Address Current Street Address Charlotte, NC 28202 Clemmons, NC 27012 City State Zip City State Zip 336-917-2522 336-917-2510 Telephone 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.. Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip 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. Patrick Sizemore Senior Engineering Technologist Type or print name Title or Authority Patrick Sizemore Digitally signed by Patrick Sizemore ��/ Date: 2021.10.11 14:05:30-04'00'16 / Signature Date I I, c-, 4-1 i c w_ a Notary Public of the County of r' State of North Carolina, hereby certify that appeared personally before me this day and being duly sworn acknowledged that the above form was execute�c��br%Mry "MO O Win •,,And nd��' ial seal, this _day of ICJ 20 a� 1 o J O= Vn C� 02-Z Notary 0 $mial -� s �Q� ems`' My commission expires tk St j5 DCa�