NCC221240_FRO Submitted_20220421

(9,_)
ROCKY MOUNT
PUBLIC WORKS
THE CENILR OF If 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 Scott. [e-mail]).
Part A.
1
2
3
4
5
Project Name Hubbell Lenoir Site Upgrades
Location of land -disturbing activity: County Nash
Address 546 English Road, Rocky Mount Latitude 35.980576
Approximate date land -disturbing activity will begin: 11/2021
Longitude-77.852076
Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
Total acreage disturbed: 1.57
6. Amount of fee enclosed: $100.00 . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Dina E-mail [e-mail]
Telephone [phone] Cell # 573-239-8596
9. Landowner(s) of Record (attach accompanied page to list additional owners):
English Road Holding, LLC 252-443-4291
Name Telephone
PO Box 8317 546 English Rd
Current Mailing Address Current Street Address
Rocky Mount NC 27804 Rocky Mount NC 27804
City State Zip City State Zip
10. Deed Book No. 1669 Page No. 52 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):
Hubbell Lenoir City, INC
Name
546 English Road
Current Mailing Address
[e-mail]
E-mail Address
546 English Road
Current Street Address

Rocky Mount NC 27804
City State Zip
Telephone [phone]
Rocky Mount NC
City State
27804
Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
State Zip
(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:
John Dina
Name of Registered Agent
PO Box 8317
Current Mailing Address
[e-mail]
E-mail Address
546 English Road
Current Street Address
Rocky Mount NC 27804 Rocky Mount NC 27804
City State Zip City State Zip
Telephone [phone]
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.
John Dina
Tynnpe or print name
'I �
P .�..
Si nature
Plant Manager
Title or Authority
/1Ga
Date
I,G,`QI ARC)r) C-W'� q!p� rX a Notary Public of the County of
State of North Carolina, hereby certify appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by hntf"""'�•,,
�.•'ySGN, Gh'�r�
Witness ri and and 'iV seal, this day of lAa(QOjC)e_ ", 20�_
NOTARY
PUBuc .:0.Notary
al .
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