NCC240428_FRO Submitted_20240220

NC Department ctf
Environmental Quality
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Received
SEDIMENTATION POLLUTION CONTROL ACT FEB 0 5 2024
EXPRESS PERMITTING OPTION
Winstone
No person may initiate any land-disturbing activity on one or more acres as covered by the r,$i8 f�rgg,�this form
and an acceptable erosion and sedimentation control plan have been completed and appWved`by`16cl=and
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 Convey Twenty Seventh Street to Lockland Avenue Retail
2. Location of land-disturbing activity: County Forsyth City or Township Winston Salem
900 Thurmond Street 36°6'20.88"N 80°15'21.96"W
Highway/Street_ Latitude(decimal degrees) 36.1058° Longitude(decimal degrees) -80.2561°
3. Approximate date land-disturbing activity will commence:January 31, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Utility Linear
5. Total acreage disturbed or uncover d (including off-site borrow and waste areas): 7.1 acres
xpress: 0 u
Regular: $800
6. Amount of fee enclosed Total: $2,800 . 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,after which 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 X❑ Enclosed © No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Vinnie Sullivan E-mail Address [e-mail]
Phone: Office# 828 258 4313 Mobile# N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Duke Energy Carolinas, LLC 760-445-3332 N/A
Name Phone: Office# Mobile#
525 South Tryon Street N/A
Current Mailing Address Current Street Address
Charlotte NC 28202-1006 N/A
City State Zip City State Zip
N/A N/A
10. Deed Book No. Page No. 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. [e-mail]
Company Name E-mail Address
525 South Tryon Street N/A
Current Mailing Address Current Street Address
Charlotte NC 28202 N/A
City State Zip City State Zip
Phone: Office# 828 258 4313 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 [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 Raleigh NC 27615
City State Zip City State Zip
Phone: Office#919-844-8360 Mobile# N/A
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 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
(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:
S&ME, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Matthew H. Kunkle, PE 704-523-4726 803-924-5523
Individual contact person (type or print) Phone: Office# 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.
Vinnie Sullivan, P.E.,C.F.M. Sr.Transmission Permitting Manager
Type or print nam Title or Autho ity
u.._
Signature Date
I, //914-6 y , a Notary Public of the County ofr-ico/ay__
State of North Carolina, hereby certify that i/ir cal/it/A-4_ 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 S day of Ll2,wuk,/ , 20 2 Y
Timoàti1
y �
Seal My commission expires 1/J4✓�_sf-4,7a0a,j'
TieetaY J.'Pesee
Notary Public
Buncombe County,NC
My Commiuion Expires'. 4 AY