NCC222913_FRO Submitted_20220822

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 Hawthorne Road Retail Abandonment
2. Location of land -disturbing activity: County Forsyth City or Township Winston-Salem
Near S. Stratford Road 36.077642 80.300869
Highway/Street Latltude(decimaldegrees) Long ltUde(decimaldegrees)
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial - Utility RE6
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 6. 1
6. Amount of fee enclosed $3,700 . 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, afterwhich 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 ❑ Enclosed ❑ No ❑x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eric Shook
Phone: Office # 336-971-4176
E-mail Address [e-mail]
Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC 704-382-6383
Name
EC09Q 526 South Church Street
Current Mailing Address
_Charlotte, NC 28202
City State
Phone: Office # Mobile #
526 South Church Street
Current Street Address
Charlotte, NC 28202
Zip City
State
Zip
10. Deed Book No. listed On plans Page No. listed on plans 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 companyis a sole proprietorship orif 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 Carolinas, LLC
Jeff.Goto@duke-energy. corn
Company Name
E-mail Address
526 South Church Street
526 South Church Street
Current Mailing Address
Current Street Address
Charlotte NC 28202
Charlotte NC 28202
City State Zip
City State Zip
Phone: Office # 704-382-6383
Mobile # [phone]
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:
Karen Rozar (CT Corporation System)
[e-mail]
Name of Registered Agent
E-mail Address
160 Mine Lake Court, Suite 200
n/a
Current Mailing Address
Current Street Address
Raleigh NC 27615-6417
n/a
City State Zip
City State Zip
Phone: Office # [phone]
Mobile #
Karen Rozar
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
n/a
Mobile # 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.
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:
Dewberry Engineers Inc.
Engineering firm or other consultant
Brian LaFranchi
Individual contact person (type or print)
[e-mail]
E-mail Address
[phone]
Phone: Office #
310-580-5146
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.
Jeff Goto
Lead Transmission Permitting Manager
Type or print name Title or Authority
(,/I' 3 12b2,2
S itfnatur Date
tom.,, �, a Notary Public of the County of
State of North Carolina, hereby certify that Go� 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 V day of , 20 Q
0j"j-4 a-2 W_':_�
Notary
Seal My commission expires ffyoc.)h
HELISIA WRIGHT
Notary Public, North Carolina
Union County
My Commission Expires
March 15, 2027

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.
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
City
State
Zip
City 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.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
State Zip
State Zip
State Zip
City State Zip City State Zip
Phone: Office # Mobile #