NCC224016_FRO Submitted_20221205

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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
The Retreat at Selma
2. Location of land -disturbing activity: County Johnston City or Township Selma Highway/Street 1791 Outlet Center Latltude(decimal degrees) 35.5196 Longltude(decimal degrees) -78.29 ['
3. Approximate date land -disturbing activity will commence: 10/24/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.3
6. Amount of fee enclosed $1750 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Rocky Keim E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners);
Selma Road Properties, LLC
Name Phone: Office # Mobile #
11608 Appaloosa Run 11608 Appaloosa Run
Current Mailing Address Current Street Address
Raleigh, NC 27613 Raleigh, NC 27613
City State Zip City State Zip
10. Deed Book No.4063/3818 Page No. 702/917 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 Worlds, LLC
Company Name
436 1 /2 Carolina Circle
Current Mailing Address
Winston Salem, NC 27104
City State
Phone: Office # 336-414-0233
[e-mail]
E-mail Address
436 112 Carolina Circle
Current Street Address
Winston Salem, NC 27104
Zip City
State
Mobile # [phone]
Zip
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 INC Secretary of State
business registry, give name and street address of the Registered Agent:
Richard C. Angino [e-mail]
Name of Registered Agent
436 1/2 Carolina Circle
Current Mailing Address
Winston Salem, NC 27104
City State
Phone: Office # 336-414-0233
E-mail Address
436 1 /2 Carolina Circle
Current Street Address
Winston Salem, NC 27104
Zip City
State Zip
Mobile # [phone]
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
FEI Consulting, Inc
Engineering firm or other consultant
Brent Sievers
Individual contact person (type or print)
bsieve [e-mail]
E-mail Address
336-544-6432
Phone: Office # Mobile #
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.
Richard C. Angino
Type or prin e
Signature
Managing Member
Title or Authority
lo-4-TOZZ
Date
Wilson D. Warren Forsyth
a Notary Public of the County of
State of North Carolina, hereby certify that Richard C. Angino 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 4th
Forsyth County, North Carolina M
Notary Public
Wilson D. Warren
'M� Commission Expires 11/3/2023
day of October 20 22
AI
Notary
My commission expires 11 / 7.0 1.3