NCC223130_FRO Submitted_20220906

10. Deed Book No. 8638 Page
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 Panda Express - High Point
2. Location of land -disturbing activity: County Guilford City or Township High Point
Highway/Street N. Main Street Latltude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: 08/01 /22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.60
6. Amount of fee enclosed: $ 1 60 . 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 0 Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Clay Worthy E-mail [e-mail]
Phone: Office # 623-572-6777 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CFT NV Developments
Name
1120 N. Town Center Drive, Suite 150
Current Mailing Address
Las Vegas NV 89144
City State Zip City
985
Phone: Office # Mobile #
Current Street Address
State
Zip
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
Company Name
1683 WALNUT GROVE AVE
Current Mailing Address
ROSEMEAD CA 91770
City State Zip
Phone: Office # 626-799-9898
N/A
E-mail Address
[e-mail]
Current Street Address
N/A
City State
Mobile # N/A
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:
CT CORPORATION
Name of Registered Agent
N/A
Current Mailing Address
N/A
City
State
N/A
E-mail Address
160 MINE LAKE COURT, SUITE 200
Current Street Address
RALEIGH NC 27615
Zip City
State Zip
Phone: Office # 623-572-6777 Mobile # [phone]
Clay Worthy
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
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State Zip
Phone: Office # N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Mobile # 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.
Type or print name Title or Authority
Signature Date
a Notary Public of the County of
State of North Carolina, hereby certify that
before me this day and being duly sworn acknowledged that the
appeared personally
rm was executed by him/her.
Witness my hand and notarial seal, this day of"" 20
G yyY�
rYR _
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 Los Angeles
On before me,
Yunyi Lu, Notary Public
(insert name and title of the officer)
personally appeared Derek Knight
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. *my
YUNYI LU
Notary Public - California
LosAngeles County
Commission # 2373745
Comm. Expires Sep 4, 2025
Signature (Seal)

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Name
Current Mailing Address
Phone: Office #
Current Street Address
Mobile #
City State
Zip
City
State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone:
Office # Mobile #
Current Mailing Address
Current Street Address
City State
City
Zip
State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Phone:
Office # Mobile #
Name
Current Mailing Address
Current Street Address
City State
City
Zip
State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone:
Office # Mobile #
Current Mailing Address
Current Street Address
City
City State
Zip
State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City
Phone: Office #
State Zip City
Mobile #
State Zip