NCC230721_FRO Submitted_20230317

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Marshall Dry Ash Landfill Phase II 1804-INDUS-1983
2. Location of land -disturbing activity: County Catawba
City or Township Sherrllls Ford
8320 NC Highway 150E 35.59750-80.96472
Highway/Street LatltUde(decimal degrees} LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: February 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 69 acres
6. Amount of fee enclosed: $ 6, 900.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Rawya Al Dulaimi
Phone: Office # 864-283-2187
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC
10
Name Phone: Office # Mobile #
400 South Tryon Street 400 South Tryon Street
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City
Deed Book No. 02954 Page No. 0421-0428
State
Zip
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 company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owners) may be listed as the financially responsible party(les).
Duke Energy Carolinas, LLC
Company Name
P.O. Box 1007
Current Mailing Address
Charlotte NC 28201-1007
E-mail Address
400 South Tryon Street
Current Street Address
Charlotte NC 28202
City State Zip City
Phone: Office # Mobile #
State
ME
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:
CT Corporation
[e-mail]
Name of Registered Agent
E-mail Address
16n Mom I aka (,'t
160 Mine Lake Ct
Curren ai ing dress
Current Street Address
Raleigh NC
27615 Raleigh NC 27615
City State
Zip City State Zip
Phone: Office # N/A
Mobile # NIA
N/A
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:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
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
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.
Type or print name Title or Authority
23/23
Signature Date
---------------------------------------------------------------------------------------------------------------------------------
I, , a Notary Public of the County of -
State of North Carolina, hereby certify that 1 , ki� n ! 1() 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 day of o C {^ , 20
U t1C.AR ---+rt-•
T RY P Notary
11OU%O .
nburg Coun
North Carolina My commission expires Cl
My Commission Expires

Continued from Item 1 in Part B 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 E-mail Address
Current Mailing Address Current Street Address
City
Phone: Office #
Company 3 Name
Current Mailing Address
City
Phone: Office #
State Zip City
Mobile #
E-mail Address
State Zip
Current Street Address
State Zip City State
Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Zip
Zip
Zip