NCC243186_FRO Submitted_20241016

ROCKY MOUNT
PUBLIC WORKS
THE CENTER OF IT ALL
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
City of Rocky Mount. (Please return to [e-mail]).
Part A.
1. Project Name: Ronnie's Truck Service
2. Location of land-disturbing activity: County: Nash
Address: 2026 Fenners Rd. Latitude: 36.004 Longitude: -77.788
3. Approximate date land-disturbing activity will begin: 4/16/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed: 3.3
6. Amount of fee enclosed: $200.00. The application fee of$50.00 per acre (rounded up to the next acre)
is assessed. (Example: For an 8.3 disturbed acreage project, the fee is $450).
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: Ronnie Mark Holland E-mail Address: [e-mail]
Telephone: [phone] Cell#: 252-237-4868
9. Landowner(s) of Record (attach accompanied page to list additional owners):
RM Holland, LLC 252-205-5001
Name Telephone
7265 Creekview Ct. Same
Current Mailing Address Current Street Address
Lucama NC 27851 Same
City State Zip City State Zip
10. Deed Book No. 3303 Page No. 236 Provide a copy of the most current deed.
Part B.
1 Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
RM Holland, LLC [e-mail]
Name E-mail Address
7265 Creekview Ct. Same
Current Mailing Address Current Street Address

Lucama NC 27851 Same
City State Zip City State Zip
Telephone: [phone]
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone:
(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:
Ronald Mark Holland [e-mail]
Name of Registered Agent E-mail Address
7265 Creekview Ct. Same
Current Mailing Address: ' Current Street Address
Lucama NC 27851 Same
City State Zip City State Zip
Telephone: [phone] Fax Number: N/A
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.
Ronnie Mark Holland Member
Type or print name v Title or Authority
AA.,
Signature Date
I, C5i'� i�/ /41 4 t/j.e.iO ZA///_//ge ___//71/..6,-
a Notary Public of the County ofAX...,50/•2/
State of North Carolina, hereby certify that 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 / day of a/lyi 20
Steven Lee Oliverio . ��
NOTARY PUBLIC -Notary
Se Wilson County,NC
My Commission Expires///16=26Z5 My commission expires /1— /fi—.ZCU--