NCC222515_FRO Submitted_20220725

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 NIA in the blank.)
Part A.
I
IF
3.
4.
5.
6.
tl
Is
Project Name Royal Farms #487 - Kinston
Location of land -disturbing activity: County Lenoir City or Township Kinston
Highway/Street W. Vernon Ave Latitude(aedmai degrees) 35.2607 Longitude(dedmei degFees)-77.6489
Approximate date land -disturbing activity will commence: July 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2'20
Amount of fee enclosed: $ Paid $300 Mari 2022 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed x❑ No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
TBD (GENERAL CONTRACTOR) E-mail Address
Phone: Office # Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Two Farms, Inc. 410-889-0200
Name Phone: Office # Mobile #
176 Mine Lake Court, Ste. 100 3611 Roland Ave
Current Mailing Address Current Street Address
Raleigh, NC 27615 Baltimore, MD 21211
City
10. Deed Book
State Zip City
1941 Page No. 332-335
State
Zip
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.
Company Name
176 Mine Lake Court, Ste. 10
Current Mailing Address
Raleigh, NC 27615
City State Zip
Phone: Office # 410-889-0200
[e-mail]
E-mail Address
3611 Roland Ave
Current Street Address
Baltimore, MD 21211
City State Zip
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:
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)
(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 narne, 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.
Sosh WoE�P, on behalf of Two Farms, Inc.
Type or print name Title or Authority
BA 0 cp J 2
Si ff
re Date
1, Me X e_ L. M%V\f-)r\M+ a Notary Public
1 of the County of CArtro1l
State of M a►r y I CLN hereby certify that � W O S l� Q\�e 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 �hd day of 7S C , 20 o2a
MELANIE LYNN MINEHART Wary
Seal Notary Public
0nh' My commission expires 6r�f'LyZt1

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:
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 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 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 Street Address
Current Mailing Address
Zip City State Zip
City State
Phone: Office #
Mobile #
E-mail Address
Company 3 Name
Current Street Address
Current Mailing 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 #