NCC243115_FRO Submitted_20241009

1.9
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_UNC Nash Patient Tower
2. Location of land-disturbing activity: County_Nash City_Rocky Mount
Street Address2460 Curtis Ellis Drive Latitude_35.976_Longitude_-77.852
3. Approximate date land-disturbing activity will begin: 10/15/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site burrow&waste areas):_9.3
6. Amount of fee enclosed: $ 1,150 - . The application fee of$250.00 for the first acre and
$100.00 per each additional acre (rounded up to the next acre) is assessed. (Example: For an 8.3
disturbed acreage project, the fee is$1,050).
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 Wes Altman E-mail Address [e-mail]
Phone: Office# 336-333-2872 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Nash Hospitals Inc 252-962-8000
Name Phone: Office# Mobile#
PO Box 7100 2460 Curtis Ellis Drive
Current Mailing Address Current Street Address
_Rocky Mount _ NC 27804 _Rocky Mount NC 27804_
City State Zip City State Zip
10. Deed Book No. 1488 Page No. 964 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).

Nash Hospitals Inc [e-mail]
Company Name E-mail Address
PO Box 7100 2460 Curtis Ellis Drive
Current Mailing Address Current Street Address
_Rocky Mount NC 27804 _Rocky Mount_ NC 27804
City State Zip City State Zip
Phone: Office# 252-962-8000 Mobile#
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 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# Cell#
Name of individual to contact, if Registered Agent is a company:
(b) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give the name and street address of the Registered Agent:
Shawn Hartley [e-mail]
Name of Registered Agent E-mail Address
PO Box 7100 2460 Curtis Ellis Drive
Current Mailing Address Current Street Address
_Rocky Mount NC 27804 Rocky Mount NC 27804_
City State Zip City State Zip
Phone: Office# 252-962-8000 Cell#
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 (DBA). 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
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.
_Shawn Hartley Corporate Financial Officer
Type or print name Title or Authority
7Z-PZ
Signature ` Date
l., QM)1O" , a Notary Public of the County of WaS' \
State of North Carolina, hereby certify that Shawn appeared
`t
personally before me this day and being duly sworn acknowledged that he above form was
executed by him.
nnor �,n�
Witness my hand and notarial seal, this l day of �Mr.�� 201_I
ota
Seal 1/
My commission expires j0� I lJ l a)(3
JODY L NAYLOR
NOTARY PUBLIC
NASH COUNTY, NC

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners.
Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Nash County 252-495-9800
Name Phone: Office# Mobile#
_120 W Washington St. Su 3072 _120 W Washington St. Su 3072
Current Mailing Address Current Street Address
_Nashville NC 27856 Nashville NC 27856
City State Zip City State Zip
Deed Book No. 884 _Page No._364-366_Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties. Attach
copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#