NCC241368_FRO Submitted_20240507

ID
4116):
ROCKY MOUNT
PUBLIC WORKS
'I:!E CENIEN CF:r 411.
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 Gabrielle.Bryson©RockyMountNC.gov).
Part A.
1. Project Name Stauffer Glove Expansion
2. Location of land-disturbing activity: County Nash
Address 4381 Dozier Road, Rocky Mount, NC 27804 Latitude 35.9738 Longitude -77.8821
3. Approximate date land-disturbing activity will begin: Summer 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed: 2.04 AC
6. Amount of fee enclosed: $ 150.00 . 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 Robbie Davis E-mail Address rdavis1352aol.com
Telephone Cell # 252.813.1508
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Stauffer Glove Safety Co
Name Telephone
PO Box 45 4381 Dozier Rd
Current Mailing Address Current Street Address
Red Hill, PA 18076 Rocky Mount, NC 27804
City State Zip City State Zip
10. Deed Book No. 1810 Page No. 0651 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):
Turn-Key Contractors of Rocky Mount, Inc. rdavis1352Aaol.com
Name E-mail Address
5530 Dortches Blvd
Current Mailing Address Current Street Address

Rocky Mount, NC 27804
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:
Turn Key Contractors of Rocky Mount, Inc. rdavis1352(a?aol.com
Name E-mail Address
5530 Dortches Blvd
Current Mailing Address Current Street Address
Rocky Mount, NC 27804
City State Zip City State Zip
Telephone [phone]
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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 t)e any change in the information provided herein.
ti3.n4 (S, GE. 0
T e or print name Title or Authority
2 0 2Li
Signature Date
I, , a Notary Public of the County of ,
State of North Carolina, hereby certify that rye' appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
- tom
Witness my hand and notarial seal, this day of `-1 1-1 , 20
Cindy Bryant Notary ;.
NashoPublic
unty, NC
My Comm. Exp.8/4/27 . My commission expires i