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HomeMy WebLinkAboutNCG020172_SW Permit DOSA_20230911 R -s, ROY COOPER .6;r f �.'l Governor •- ELIZABETH S.BISER ` ra+• Secretary �'`' ,"r DOUGLAS R.ANSEL NORTH CAROLINA Interim Dlr, Environmental Quality Stormwater Delegation of Signature Authority Form (DOSA) This form shall be used to delegate signature authority from the permit Owner (Permittee) to another party. Only the Responsible Official defined below may submit permit applications and reports required by the permit (such as Data Monitoring Reports and Annual Reports) until this form is completed and submitted to the DEMLR Stormwater Program. Please note that delegating signature authority does not relieve the Permit Owner from the responsibility and compliance for permit compliance, Permit Owner:The legal entity to which/whom a permit has been issued and may be an individual or an organization such as a company or government agency. Every Owner is required to have a Responsible Official who meets the legal signature authority requirements in 40 CFR 122.22, summarized below: • Fora corporation,the Responsible Official shall be a president,secretary,treasurer,or vice president in charge of a principal business function,or another individual who performs similar functions for the corporation,or the manager ofone or more manufacturing,production,or operating facilities who is authorized to make management decisions about the facility operation. • For a partnership or sole proprietorship,the Responsible Official shall be a general partner or the proprietor,respectively;or • For a municipality,State,Federal,or other public agency,the Responsible Official shall be either a principal executive officer[City/County Manager]or ranking elected official[Mayor]. Please mail the DOSA Form with original wet signatures to: NCDEMLRStormwater Program, 1612 MSC,Raleigh, NC 27699-1612 Name of Organizational Entity Vulcan Construction Materials, LLC Responsible Official Name Jack Marsh Responsible Official Title: Vice President of Operations Email Address Phone marshj@vmcmail.com 336-767-4600 Mailing Address 4401 N. Patterson Ave. City State Zip code Winston Salem NC 27105 D_E Q North Carolina Department of Environmental Quality Division of Energy Mineral and land Resources 512 North Salisbury Street 1612 Mail Service center Raleigh.North caroling 27699-1612 t �ds..\/'" 9'9'079200 A. Persons to Receive Signature Authority The signatures of the persons listed below indicates their acceptance of signatory authority. Attach additional pages if you need more space. Delegated Party Name Tony Johnson Delegated Party Title Environmental Engineer Permit Number(s) Please See Attached Permit Numbers List Email Address johnsonto@vmcmail.com Phone 571-422-6401 Mailing Address 11020 David Taylor Drive, Suite 400 City Charlotte State NC Zip code 28262 Signature of Delegated Party indicating acceptance of Signatory Authority: I Date Y'. #Z-3 Delegated Party Name Delegated Party Title Permit Number(s) Email Address: Phone Mailing Address City State Zip code Signature of Delegated Party indicating acceptance of Signatory Authority: Date Delegated Party Name Delegated Party Title Permit Number(s) Email Address Phone Mailing Address City State Zip code Signature of Delegated Party indicating acceptance of Signatory Authority: Date Stormwater Permit Delegation of Signatory Authority Form Page 2 B. Responsible Official Signature The Responsible Official,as identified in accordance with 40 CFR 122.22, is the appropriate individual with the authority to sign and submit reports for the organization. As the Responsible Official,I, Jack Marsh (printed name), have the authority to enter into this Agreement for Vulcan Construction Materials, LLC _ (Owner/Organization Name). I request that the DE MLR Stormwater Program include the persons listed in Part A of this form signatory authority for the above-named permit. I acknowledge that I,and the persons listed in Part A of this form work at/for my organization and have authority to act as a signatory for purposes of the N CD EQ's electronic document systems. By submitting this application,1, Jack Marsh (printed name),have read, understand,and accept the terms and conditions of the stormwater permit(s) for which I am the Responsible Official. fit sponsible Official Signature Vice President of Operations Zp z3 Title Da, Stormwater Permit Delegation of Signatory Authority Form Page 3 Vulcan Construction Materials, LLC North Carolina Delegation of Signature Authority Form Permit Numbers Quarry Permit No. 115 NCG020160 421 NCG020910 Boone NCG020251 Cabarrus NCG020172 Clear Creek NCG020201 East Forsyth NCG020115 Elkin NCG020159 Enka NCG020151 Gold Hill NCG020108 Hendersonville NCG020176 High Shoals NCG020190 Lenoir NCG020026 Morganton NCG020177 North NCG020082 Penrose NCG020046 Pineville NCG020049 Rockingham NCG020107 Rowan NCG020310 Smith Grove NCG020081 South Fork NCG020441 Spruce Pine NCG020511 Stokesdale NCG020191 Yadkin NCG020183 Burke NCG020691 North 321 NCG020863