NCC230123_FRO Submitted_20230117

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.
Project Name Royal Farms - Store #493
2. Location of land -disturbing activity: County P
City or Township Greenville
Highway/StreetMLK Blvd. & NC 33 E.Latitude 35.62667 Longitude-77.33032
3. Approximate date land -disturbing activity will commence: Apr il 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.00 acres
6. Amount of fee enclosed: $ 700.00 . 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 [e-mail]
Telephone [phone] Cell # 252-646-2257
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Trade Land Company LLC
Name
3675 Marine Drive
Current Mailing Address
Greenville NC 27834
City State Zip
252-902-7300
Telephone Fax Number
3675 Marine Drive
Current Street Address
Greenville NC
City
State
27834
Zip
10. Deed Rook No. 3687 Page No. 825 Provide a copy of the most current deed.
Part B.
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
[e-mail]
E-mail Address
3611 Roland Ave.
Current Street Address
Baltimore MD 21211 Baltimore MD 21211
City State Zip 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
N/A
E-mail Address
176 Mine Lake Court, Ste. 100
Current Street Address
Raleigh NC 27615 Raleigh
City State Zip City
Telephone [phone]
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax
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 by any change in the information provided herein.
Chris ollin Construction Manager (Delegated Agent)
e Title or Authority
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Signature Date
I, ►v1 1 a�i�P , ��� r-� , a Notary Public of the County of Cawv-011
State of MARYL*MD hereby certify that rh d,:S %1 appeared
personally before rn, this day and being duly sworn acknowledged that the above form was
executed by him.
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Witness my hand and notarial seal, this day of , 20
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Seal MELANIE LYNN MINEHART otar
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My commission expires
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