NCC222562_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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (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.
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3
4
5
Project Name Royal Farms - Store #486
Location of land -disturbing activity: County Pitt City or Township Greenville
Highway/StreetE. 14th St. & US Hwy. 264 Latitude 35.59018 Longitude-77.34564
Approximate date land -disturbing activity will commence: June 1, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3 acres
6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre (rounded
to the tenth of 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, PE E-mail Address dan(a)arkconsultinggroup.com
Telephone [phone]
Cell # 252-646-2257 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ward Holdings, LLC
Name
252-355-7993
Telephone
503 Chesapeake Place 503 Chesapeake Place
Current Mailing Address Current Street Address
Fax Number
Greenville NC 27858 Greenville NC 27858
City State Zip City State Zip
10. Deed Book No. 2350 Page No. 817 Provide a copy of the most current deed.
2906 419
Part B. 2350 829
2917 304
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):
Two Farms, Inc.
Name
3611 Roland Ave.
Current Mailing Address
Baltimore MD 21211
City State Zip
[e-mail]
E-mail Address
3611 Roland Ave.
Current Street Address
Baltimore MD 21211
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
176 Mine Lake Court. Ste. 100
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephone [phone]
NIA
E-mail Address
176 Mine Lake Court Ste. 100
Current Street Address
Raleigh
City
Fax Number
NC 27615
State Zip
(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 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 by any change in the information provided herein.
Chris Bo G o Construction Manager (Delegated Agent)
Type r Title or Authority
3 �
n aO re Da e
I, �=8b ' o a Notary Public of the County of 6a [ 1 Y cyr_ Cli7�`�
state of MAylland, hereby certify that Cky-, S Lit idd 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 I day of M�� , 20 0�
Notary
Seal
exilres
FELICIA KOHLHEPP
Notary Public-Maryfand
Baltimore city
My Commission Expires
Januery 14, 202.1