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HomeMy WebLinkAboutNCC232315_FRO Submitted_20230803 Check if this project is ARPA-funded g, FINANCIAL RESPONSIBILITY/OWNERSHIP FORM 3 i SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land-disturbing activity on one or more acres as covered by the Act, includEng_eny activity under a common plan of development of this size as covered by the NCGO1 permit, before this.fQr'm and an acceptable erosion and sedimentation control plan have been completed and approved by the La"rd 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. Allen South Starter Landfill Construction, Operations, and Closure 1. Project Name Revision to Previously Approved GASTO-2021-014 *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 Gaston City or Township Belmont Highway/Street 253 Plant Allen Rd Latitude(aecimal 35.18984 N Longitude(decimaldegrees) 81.00884 N 3. Approximate date land-disturbing activity will commence: May 2023 for additional work submitted under revision Industrial 4. Purpose of development (residential, commercial, industrial, institutional, etc.): 58.5 acres(55 acre previously;3.5 acres for 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):revision) 6. Amount of fee enclosed: $ 400 for revision . 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 II No 0 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Elizabeth Glenn E-mail Address Elizabeth.Glenn@duke-energy.com Phone: Office# 980-373-0530 Mobile# 864-642-8833 9. Landowner(s)of Record (attach accompanied page to list additional owners): Multiple Deeds-see attached sheet Duke Energy Carolinas LLC 980-373-6211 N/A Name Phone: Office# Mobile# 526 South Church Street ECI-05A 526 South Church Street ECI-05A Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip 10. Deed Book No. 4427 Page No. 2075 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 sarah.santos@duke-energy.com Company Name E-mail Address 526 South Church Street ECI-05A 526 South Church Street ECI-05A Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip Phone: Office# 980-373-6211 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 N/A Name of Registered Agent E-mail Address 160 Mine Lake Ct, Suite 200 160 Mine Lake Ct, Suite 200 Current Mailing Address Current Street Address Raleigh NC 27615 Raleigh NC 27615 City State Zip City State Zip Phone: Office# 919-821-7139 Mobile# N/A John Weber 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. i/ 1. /.4 #1, 044 4 o ot; Geviereil arteiaet Type or print ►ame Title or Authority 7- 12— 20 3 Signature Date I, \. _ (�� , a Notary Public of the County of 14.K.R.Qn xi-8 State of North Carolina, hereby certify that a�( Inc• lock( 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 L day of --1—L,I , 20 U(.\\ J afitt.t) , . k(ot) Notary • My commission expires(:)4� ) 16.1-1 lanburg Count North Carolina My Commission Expires •, L Y A O 4 | } 2 $ r1 } . Allen Steam Station South Starter Landfill E&SC Plan GASTO-2023-015 Deed Book Page Acreage 190 179 135 194 374 19.95 674 444 6.46 878 551 0.97 878 555 0.56 894 364 25.1 914 466 45.83 1016 56 5.48 1084 182 0.94 1084 837 13.68 1086 276 0.43 1090 516 13 1094 496 1.96 1182 370 107.5 4427 2075 62