NCC222724_FRO Submitted_20220729

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 American Leadership Academy Offsite Roadway Improvements
2. Location of land -disturbing activity: County Johnston City or Township Smithfield
US Hwy. 70 Business 35.562648-78.391545
Highway/Street_ LatltUde(decimaldegrees) Long ltUde(decimaldegrees)
3. Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Educational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.88
6. Amount of fee enclosed 300 + 750 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). 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 Jeff Rush E-mail [e-mail]
Phone: Office # 810-225-2001 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Johnston CD, LLC 801-830-8300 801-830-8300
Name Phone: Office # Mobile #
3115 East Lion Lane, Suite 300 3115 East Lion Lane, Suite 300
Current Mailing Address Current Street Address
Salt Lake City, UT, 84121 Salt Lake City, UT, 84121
City State Zip City State Zip
10. Deed Book No. 06095 Page No. 0210 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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Johnston CD, LLC
Company Name
3115 East Lion Lane, Suite 300
Current Mailing Address
Salt Lake City, UT, 84121
[e-mail]
E-mail Address
3115 East Lion Lane, Suite 300
Current Street Address
Salt Lake City, UT, 84121
City State Zip City State Zip
Phone: Office # 801-278-0800 Mobile # [phone]
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:
NA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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:
NA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Ballentine Associates, PA
Engineering firm or other consultant
Lee Price
Individual contact person (type or print)
[e-mail]
E-mail Address
919-929-0481
Phone: Office #
252-531-3203
Mobile #
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.
Scott Brand
Type or print name
Signature
Manager
Title or Authority
Date
I, , a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of , 20
Notary
Seal My commission expires

(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.
NIA
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.
Scott Brand
Signature
Jacqueline Wilson
Manager
Title or Authority
5/24/22
Date
a Notary Public of the County of Salt Lake
LAAIA Scott Brand
State of , hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 24 day of May
w "eft JACQUELINE WILSON
R *� Notary Public - State of Utah
comet, No. 710578
My co FMl"teb n20Y4r�5 on
2022
Notar
My commission expires 2'/ 1 4/2024