NCC230736_FRO Submitted_20230320

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.
1. Project Name_ Ro yal Farms - Store #540
2. Location of land -disturbing activity: County Pitt City or Township Greenville
3.
4.
5.
6.
7
t3
E
Highway/Street us-13 & Frog Level Rd. Latitude 35.572118 Longitude-77.444705
Approximate date land -disturbing activity will commence: February 1, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.6 acres
Amount of fee enclosed: $ 560.00 . 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).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dan Withers PE E-mail Address dan arkconsultin rou .corn
Telephone [phone] Cell # 252-646-2257
Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Hunter & Olivia Nichols
Name
3011 Herman Garris Rd.
Current Mailing Address
Greenville
City
NC 27858
State Zip
Telephone
3011 Herman Garris Rd.
Current Street Address
Fax Number
Greenville NC 27858
City State Zip
10. Deed Book No. 3499 Page No. 481 Provide a copy of the most current deed.
3643 30
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. [e-mail]
Name E-mail Address
3611 Roland Ave. 3611 Roland Ave.
Current Mailing Address Current Street Address
Baltimore MD 21211 Baltimore MD
City State Zip City State
Telephone [phone]
Fax Number
V
1

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:
Re istered A ent Solutions, Inc.
Name
176 Mine Lake Court, Ste._100
Current Mailing Address
Raleirih
City
NC
State
Telephone [phone]
N/A
E-mail Address
176 Mine Lake Court- Ste. 100
Current Street Address
27615 Raleigh
Zip 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
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.
OChrisBine
Construction Manager (Delegated Agent)
Title or Authority
10118 Da>a
Date
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I, M kP L, WP� , a Notary Public of the County of OU-
State of Ro.rjlc^d, hereby certify that iJ61 t (AO 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 I8!" day of UC_' Obe , 20)a_
KLANHE-LANNMINEHART .
Notary PubNc N tary
Seal Carrot County, M�IaryIIand
*CMVi8ftE*1Ms1/2IIrM My commission expires O/ 2B �1