NCC241443_FRO Submitted_20240510

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, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Royal Farms—Store#565
2. Location of land-disturbing activity: Wayne County City or Town: City of Goldsboro
Highway/Street 800 W.Grantham St.. LatitUde(decimal degrees) 35.397412 LOngitUde(decimal degrees) 78.005547
3. Approximate date land-disturbing activity will commence:_ June. 1 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.10
6. Amount of fee enclosed: $_700.00 _ . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee
is$900). Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kenneth Judy, PE E-mail Address Kenneth.Judy( ArkConsultingGroup.com
Phone: Office# 252-558-0888 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Cit, of Goldsboro
Name Phone: Office# Mobile#
PO Box A
Current Mailing Address Current Street Address
Goldsboro NC 27533
City State Zip City State Zip
10. Deed Book No._3087&3560 Page No._19 &320_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).
Two Farms Inc. [e-mail]
Company Name E-mail Address
3611 Roland Ave.
Current Mailing Address Current Street Address
Baltimore MD 21211
City State Zip City State Zip
Phone: Office# i4101 484-7010 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 a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Registered Agent Solutions Inc.
Name of Registered Agent E-mail Address
176 Mine Lake Court, Ste. 100
-
Current Mailing Address Current Street Address
Raleiuh_ _ NC 27615
City State Zip City State Zip
Phone: Office# 888-705-7274 Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(b) 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# Mobile#
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. 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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Joshua Wolfs CFO
Ty e or print name Title or Authority(/
034(y
'gna L r Da e
I, 44-itair(- arks 1 +' a Notary Public of the County of
State of f l
, hereby certify that '<_ i!©� �, tv� - appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this -12 day of wt,trcGt , 2024
&,r
No ry
Seal
My commission expires 43/2024,4
KATHERINE MARKS RETER
Notary Public-Maryland
Carroll County
My Commission Expires
September 23,2024

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:
_Shree OM Inc
Name Phone: Office# Mobile#
_12604 Village Springs Rd.
Current Mailing Address Current Street Address
_Raleigh NC 27614
City State Zip City State Zip
Deed Book No. 3660 Page No._602 Provide a copy of the most current deed.
Landowner 3 of Record:
_Coward H Lee
Name Phone: Office# Mobile#
_415 Dogwood Trl -
-
Current Mailing Address Current Street Address
_Goldsboro NC 27534
City State Zip City State Zip
Deed Book No._3260 Page No._675 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 9 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#