NCC230821_FRO Submitted_20230327

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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.
Project Name Active Ash Basin Perimeter Vegetation Clearing and Ash Removal
"If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI)
2. Location of land -disturbing activity: County Catawba City or Township Sherri Is Ford
8320 NC-150 35.5969°-80.9663'
Highway/Street Latltude(decimaldegrees) LOngltude(decimaldegrees)
3. Approximate date land -disturbing activity will commence: Spring 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 59.8 acres
6. Amount of fee enclosed: $ 6,000 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a 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 0 No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Rawy a Al Dulaimi E-mail Address [e-mail]
Phone: Office # 864-283-2187 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC 704-382-4585
Name
526 S. Church Street
Current Mailing Address
Charlotte NC
City State
10. Deed Book No. 2954
Phone: Office #
526 S. Church Street
Current Street Address
28202 Charlotte NC
Zip City
Page No. 421-428
State
N/A
Mobile #
28202
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 owner(s) may be listed as the financially responsible party(ies).
Duke Energy Carolinas, LLC
Company Name
526 S. Church Street
Current Mailing Address
Charlotte NC 28202
City State Zip
Phone: Office # 704-382-4585
NO
E-mail Address
526 S. Church Street
Current Street Address
Charlotte NC 28202
City State Zip
Mobile # N/A
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 System
Name of Registered Agent
160 Mine Lake Court, Suite 200
Current Mailing Address
Raleigh NC 27615
City
Phone: Office # N/A
N/A
State Zip
[e-mail]
E-mail Address
160 Mine Lake Court, Suite 200
Current Street Address
Raleigh NC 27615
City State Zip
Mobile # 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:
NIA
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State
N/A
E-mail Address
N/A
Current Street Address
_ N/A
Zip City State Zip
Phone: Office # N/A Mobile # N/A
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.
N/A
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.
David Dellario
Type or print name
�:
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Signature
GM CCP Project Management
Title or Authority
/-3cs,Z3
Date
`'
�a Notary Public of the County of N4 Q,
State of North Carolina, hereby certify that \ Y #� 1�t R%I G appeared personally J
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: ay of 7�p,_, 20
TSPIEAR' Nota
RY PUBL{C
nburg County My commission expires
North Carolina
My Commission Expires

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.
Landowner 2 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 3 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 4 of Record:
State Zip
Provide a copy of the most current deed.
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 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
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State
Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # 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
Zip
Zip
Zip
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #