NCC221286_FRO Submitted_20220405

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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
Project Name Royal Farms #467 — New Bern _
Location of land -disturbing activity: County Craven City or Township New Bern
Highway/Street 3706 Dr. M.L.K. Jr. Blvd. Latitude 35.0974
Approximate date land -disturbing activity will commence:_ April 2022
Longitude-77.1033
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.0 acres
Amount of fee enclosed: $400.00 The application fee of $100.00 per acre (rounded up to the
next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
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 Dan Withers, P.E. E-mail Address [e-mail]
Telephone [phone] Cell #_252-646-2257
Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Landon Minges
Name Telephone
N/A
Fax Number
P.O. Box 520 128 Pepsi Way
Current Mailing Address Current Street Address
_Ayden NC 28513 AVden NC 28513
City State Zip City State Zip
10. Deed Book No. 1793
Part B.
Page No. 0331 Provide a copy of the most current deed.
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. realestateCdroyalfarms.com
Name E-mail Address
3611 Roland Ave. 3611 Roland Ave.
Current Mailing Address Current Street Address
Baltimore MD 21211 Baltimore
City State Zip City
MD
State
21211
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
176 Mine Lake Court, Ste. 100
Current Mailing Address
E-mail Address
176 Mine Lake Court, Ste. 100
Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephon
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
Telephone
Fax Number
State Zip
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.
John Kemp President
.ype or print nam Title or Authority
/2
sign ure Date
i, GAI G V_(akt , a Notary Public of the County of B61l l itnore_ C%y
State of MAv 1([qnd, hereby certify that TGh\n i[eMP 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 '7-2 ,vi day of Febvo utrt! , 20 '2Q
1�4
Notary YO
Seal ,e` EMyNotary
LICIA KOHLHEPP
Public-NMWbOl�)miSSi n expires 1 1 aaa3
Baltimore City
ommission Expires
anuary 14, 2023