NCC240195_FRO Submitted_20240123

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ROCKY MOUNT
PUBLIC WORKS
THE CENTER OF LT ALL
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
City of Rocky Mount. (Please return to Scott.Miles©RockyMountNC.gov).
Part A.
1. Project Name: Panda Express
2. Location of land-disturbing activity: Within the property lines and into the Jeffreys Road right-of-way.
County: Nash
Address: Jeffreys Rd & Benvenue Road Rocky Mount, NC 27804
Latitude: 35°58'39.5" Longitude: 77°48'29"
3. Approximate date land-disturbing activity will begin: 02/01/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed: 1.33 AC.
6. Amount of fee enclosed: $100. The application fee of$50.00 per acre (rounded up to the next acre) is
assessed. (Example: For an 8.3 disturbed acreage project, the fee is$450).
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: Joe Celento E-mail Address:joe.celento(a�pandarq.com
Telephone: [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Hagle Marc& Sharon Charitable N/A
Name Telephone
270 West New England Ave. 270 West New England Ave.
Current Mailing Address Current Street Address
Winter Park, FL 32789 Winter Park, FL 32789
City State Zip City State Zip
10. Deed Book No.: 3186 Page No.: 735 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):
Panda Express, Inc. [e-mail]
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
Telephone: [phone]
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone: N/A
(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:
CT Corporation N/A
Name of Registered Agent E-mail Address
N/A 160 Mine Lake Court, Suite 200
Current Mailing Address Current Street Address
N/A Raleigh, NC 27615
City State Zip City State Zip
Telephone: [phone] Fax Number: N/A
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 be any change in the information provided herein.
DCREV_ KN‘ "C eNtecAk 9)-�c-1D2 C.XASTQuC(ION
Type or print name Title or Authority
Signature Date
, a Notary Public of the County of
State of North Carolina, ereby certify that appeared
personally before me th day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, •'s day of , 20
Notse See offal .

Notary
Seal
My commission expires

1

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
) ss.
COUNTY OF LOS ANGELES
On Oc}ober 13 , 2023 , before me, (q-ene Olu/il l o , Notary Public,
personally appeared Derek V411( t- , who proved to me on the basis of satisfactory
evidence to be the person(g) whose name is/are-subscribed to the within instrument and
acknowledged to me that he/arc/they executed the same in his/weir authorized capacity(lesl,
and that by his/hcr/thcir signatureks`) on the instrument the personcsl, or the entity upon behalf of
which the person(pcacted, 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.
i 4 G
► I )avv
Notary Notary Public
= Los Angeles County
Commission if 2422971 State of California
• My Comm.Expires Oct 23,2026
My commission expires: In /2-3' 26 2 to

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