NCC230954_FRO Submitted_20230404

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 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.1. Project Name Roxboro Afterbay Dam Project
2. Location of land-disturbing activity: County Person City or Township Semora
Highway/Street Edwin Roberston Road Latitude 36.5229 Longitude-78.9982
3. Approximate date land-disturbing activity will commence:June 15, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Power Generation
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 68.3
6. Amount of fee enclosed: $ $4,485 . 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 Emily Young, PE E-mail [e-mail]
Telephone[phone] Cell# N/A Fax# N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Progress, LLC [phone] [phone]
Name Telephone Fax Number
PO Box 1551-PEB3A 1700 Dunnaway Rd.
Current Mailing Address Current Street Address
Raleigh North Carolina 27602 Semora North Carolina 27343
City State Zip City State Zip
10. Deed Book No. 98 Page No.267 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 Progress, LLC [e-mail]
Name E-mail Address
1700 Dunnaway Rd. 1700 Dunnaway Rd.
Current Mailing Address Current Street Address
Semora North Carolina 27343 Semora North Carolina 27343
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
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
Telephone N/A Fax Number N/A
(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:
Schnabel Engineering South, P.C. [e-mail]
Engineering Firm or other consultant E-mail Address
Samuel K. Kees, P.E. [phone] N/A
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.
Emily Young, PE Sr Project Manager PMC Hydro Project Program
Type or print name Title or Authority
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S gnature Date
I, i<I J EGO 4 KIN , a Notary Public of the County of IZ I (Nt It .i Co
State of North Carolina, hereby certify that EMu�Y AmbERstt1 `(o,AN 4 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 12�day of .knu. - 2023
/
Notary G
F.eal Kijeong Kim NOTARY PUBLIC My commission expires I 2-�n/ ,r
Richmond County _ 3-I'S—
North Carolina Kijeong Kim
My Commission Expires December 10,2025 NOTARY PUBLIC
Richmond County
North Carolina
My Commission Expires December 10,202'