NCC230187_FRO Submitted_20230123

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 N/A in the blank.)
Part A.
1. Project Name Ro al Farms —Store #521
2. Location of land -disturbing activity: Tyrrell County City or Town: Town of Columbia
Highway/Street US-64 & L A Keiser Dr.. Latltude(decimal degrees) 35.918604 Longitude(decimal degrees) 76.240500
3. Approximate date land -disturbing activity will commence: February 1 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): —Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.0
6. 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: 8.10-acre application fee
is $900). Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kenneth Jud PE E-mail Address_ Kenneth.Judv d-.ArkConsultin Grou .com
Phone: Office # 252-558-0888 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Spark Heights LLC
Name Phone: Office # Mobile #
117 Ashcroft Ct -
Current Mailing Address Current Street Address
Rocky Mount NC 27804
City State Zip City State Zip
10. Deed Book No. 248 Page No. 680 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
3611 Roland Ave.
Current Mailing Address
realestate ro alfarms.com
E-mail Address
Current Street Address
Baltimore MD 21211
City State Zip City
Phone: Office # (410] 484-7010 Mobile #
State
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 NC Secretary of State
business registry, give name and street address of the Registered Agent:
Registered Agent Solutions, Inc.
Name of Registered Agent E-mail Address
176 Mine Lake Court Ste. 100
Current Mailing Address Current Street Address
Raleia_ h NC 27615 _
City State Zip City
Phone: Office # 888-705-7274 Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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
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.
Joshua Wolf CFO
Typq or print name A Title or Authority
Sig
h 1IS ��
Date
L. �Jl`�Q�� a Notary Public of the County of Oaacco-U
State of Mewl la nd , hereby certify that h oct W OL� 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 15 day of %)Ovc M , 20 � ;�-
MELANIE LYNNM E N tary
Seal 0 No
County, and My commission expires !� Z
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