NCC242896_FRO Submitted_20240919

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM ckrntersvifle
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Soil Erosion and Sedimentation Control Ordinance NORTH CAROLINA
Instructions: No person shall initiate any land-disturbing activity on one or more acres, as covered in the Town of
Huntersville Soil Erosion and Sedimentation Control Ordinance, before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Huntersville. The Financially
Responsible Party will be on record as the party to accept any Notices of Violation or related documents for any non-
compliance of the Town of Huntersville Soil Erosion and Sedimentation Control Ordinance. If the Financially
Responsible Party resides out of state,a North Carolina agent must be assigned. All items on this form must be
filled out accurately and completely.
PART A - PROJECT AND LANDOWNER INFORMATION
1. Project name Panda Express- Huntersville
2. Address ofland-disturbing activity (number, street) PIN: 019-131-82 ; Cane Creek Drive
3. Approximate date land-disturbing activity will begin 08/05/2024
4. Purpose of development (Commercial, Residential, Commercial
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered 1.17
6. Total site acreage 1.16
7. Landowner(s)of Record. The names listed below must match the Deed(s).Attach a list ofadditional owners, if
applicable.
Note: If the landowner of record is not the person(s)firm(s),or Company's Financially Responsible Party,
as listed in Part B, item 1, a separate Letter of Consent,signed and dated by the Landowner of
Record, or their Authorized Agent, is required.
Landowner 1 of Record
Company Name Panda Express Contact Name Clay Worthy
Inapplicable
Mailing Address 1683 Walnut Grove Ave. Rosemead CA, 91770
Physical Address 1683 Walnut Grove Ave. Rosemead CA, 91770
If PO Box listed above
Phone [phone] Email [e-mail]
Landowner 2 of Record
Company Name Contact Name
I/applicable
Mailing Address
Physical Address
If PO Box listed above
Phone I Email I
8. Indicate the Deed Book and Page number the deed or instrument is filed. Attach a list of additional deeds if
applicable.
Deed Book Page Deed Book Page f Deed Book Page
25520 147
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 2

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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
Soil Erosion and Sedimentation Control Ordinance NORTH C A R O L I N A
PART B — FRO AND NC REGISTERED AGENT
1. Person(s), firm(s) or Company who is/are financially responsible for this land-disturbing activity.
Financially Responsible Party
Company Name (if applicable) Panda Express, Inc. Contact Name Joe Celento
Mailing Address 1683 Walnut Grove Ave Rosemead, CA 91770
Physical Address
If PO Box listed above
Phone 626_799_9898 Email [e-mail]
2. If the Financially Responsible Party listed above does not reside in the state of North Carolina, they must
provide a designated North Carolina agent below. This agent must be registered with the NC Secretary of State.
North Carolina Agent for Financially Responsible Party
NC Registered Agent Name CT Corporation Contact Name
Mailing Address 160 Mine Lake Court Suite 200 Raliegh,NC 27615
Physical Address 160 Mine Lake Court Suite 200 Raliegh,NC 27615
If PO Box listed above
Phone [phone] Email
3. (Optional)Additional contact familiar with the site,who understands the plans,and may represent the company.
Site Contact's Name Email
Phone: Office Phone: Mobile
PART C — SIGNATURE WITNESSED BY A NOTARY PUBLIC
DO NOT SIGN THIS FORM UNTIL YOU ARE TN THE PRESENCE OF A NOTARY PUBLIC
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. If the
Financially Responsible Owner is not an individual, this form must be signed 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 here4c -)
n.Printed Name 4L / � Title or Authority et ec �i-
Wet-Ink Signature Date
I, J//,ei.v
a Notary o�the Count of
Sta , hereby certify that personally
appeared before met ns being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of , 20
(seal)
Notary Signature
sl tACHP./0
My Commission Expires
Rev. 8/2022 Page 2 of 2

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 Los Angeles
On AYE-IL 2, 9-021 before me, Yunyi Lu, Notary Public
(insert name and title of the officer)
personally appeared Roger Goldstein
who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s)on the instrument the
person(s), or the entity upon behalf of which the person(s) 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. . p YUNYI LU
Notary Public-California
Los Angeles County F.
,T.grg f- Commission r 2373745
Mar; My Comm.Expires Sep 4,2025
Signature (Seal)