NCC221581_FRO Submitted_20220429

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 Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, it the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Royal Farms Store #443
1. Project Name y
2. Location of land -disturbing activity: County Currltuck City or Township Grandy
Highway/Street 6511 Caratoke Hwy Latitude 36.2396 Longitude-75.8752
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas); 3.77
6. Amount of fee enclosed: $ 260 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Andy Mueller E-mail Address [e-mail]
Telephone [phone] Cell # 301-922-3962 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached List
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Two Farms Inc. [e-mail]
Name E-mail Address
3611 Roland Ave. 3611 Roland Ave.
Current Mailing Address Current Street Address
Baltimore, MD 21211 Baltimore, MD 21211
City State Zip City State Zip
Telephone[phone] Fax Number

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:
Registered Agent Solutions, Inc
Name E-mail Address
176 Mine Lake Ct, Suite 100 176 Mine Lake Ct, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number
(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 Numbe
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.
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Type or print name
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Title or Authority
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Date
I, jar s dAiAL , a Notary Public of the County of Ca I'V- !
State of MaYY Panc( , hereby certify that _ 7�nh n 1 v`. K—emo 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 l SAday of FCbK_()aVV 207 Q
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MELANIE LYNN
Notary Pubilc N ary
c4MOU1tty, IAA IP.Nt
My Com-f`�w Expdres 1281? 4 My commission expires 1 ';Z