NCC233336_FRO Submitted_20231108

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Panda Express
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
N/A 2. Location of land-disturbing activity: County Wayne,A/
aYne City or Township Goldsboro
Highway/Street N. Berkeley Blvd. Latltude(decimalaegrees)35'37 Longitude(decimal degrees)-77.95
3. Approximate date land-disturbing activity will commence: 1 0/01/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.33
6. Amount of fee enclosed: $300 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Joe Celento E-mail Address [e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Phil Buchheit [phone] [phone]
Name Phone: Office# Mobile#
364 S. Pine St., Ste. B230 364 S. Pine St., Ste. B230
Current Mailing Address Current Street Address
Spartanburg SC, 39302 Spartanburg SC, 39302
City State Zip City State Zip
10. Deed Book No. 733 Page No. 152 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).
Panda Express, Inc. [e-mail]
Company Name E-mail Address
1683 Walnut Grove Ave 1683 Walnut Grove Ave
Current Mailing Address Current Street Address
Rosemead, CA 91770 Rosemead, CA 91770
City State Zip City State Zip
Phone: Office# 626-799-9898 Mobile# N/A
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:
CT Corporation N/A
Name of Registered Agent E-mail Address
N/A 160 Mine Lake Court, Suite 2.00
Current Mailing Address Current Street Address
N/A Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# Mobile# [phone]
Joe Celento
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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
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.
V KN16Nj e) WTI Dt cc oe Cows-cguc iocd
Type or print name Title or Authority
' /6 /23
gnature Date
I, \ , a Notary Public of the County of
State of North Car • hereby certify that appeared personally
before me this day and bei I sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of , 20
Notary
My commission expires

ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of Le ,,2..\..e-5
On 1 r ' Zoz 3 before me, 011/4.1-;% "I Q�e�;
(insert name and title of the officer)
personally appeared .e r-e. lc G� �-�—
who proved to me on a basis of satisfactor evidence to be the perso ,s1 whose name( are
subscribed to the within instrument and acknowled•ed to me that1she/they executed the same in
his/her/their authorized capacity(ies), and that b d'her/their signature(s'jon the instrument the
persons$, or the entity upon behalf of which the person,(4) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
GENESIS MURILLO
roir'Z' Notary Public•Gitfornia3 - Los Angeles County
44""` My Comm.lExpves Oct 23,2024
Signature r (Seal)