NCC231856_FRO Submitted_20230621

ROCKY MOUNT
PUBLIC WORKS
THE CENTER OF.1 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 Murphy Express (N Wesleyan & Sutter's Creek)
2. Location of land-disturbing activity: County Nash
Address 953 N Wesleyan Blvd Latitude 35.969730 Longitude -77.809930
3. Approximate date land-disturbing activity will begin: June 19, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed: 1.2
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 Goetz E-mail Address [e-mail]
Telephone [phone] Cell# 870-814-4106
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Woodhaven Rocky, LLC
Name Telephone
8317 Six Forks Road Suite 201
Current Mailing Address Current Street Address
Raleigh- NC 27615
City State Zip CityState Zip
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10. Deed Book No. 3159 Page No. 628 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):
Murphy Oil USA, Inc. [e-mail]
Name E-mail Address
200 Peach Street 200 Peach Street
Current Mailing Address Current Street Address

El Dorado AR 71730 El Dorado AR 71730
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:
CT Corporation System
Name E-mail Address
160 Mine Lake Court Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615
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:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Court Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615
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�1Q n
information provided herein. (� I
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Type or print name 3 Title or Authority
Signat Date '
I, ,G(,vc& p,,ey , a Notary Public of the County of Uu;,N
/gifs?s. 1 State of Dlorth rolina, hereby certify that 2fiviv;Ge &les appeared
personally before me this day and beingy sworn ackno !edged that the above form was
executed by him.
Witne rvOrthitakin otarial seal, this i.P` day of Waif , 20 a3
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