NCG140344_SW Permit DOSA_20230816

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ROY COOPER 160 --- . �, '
Governorei.
ELIZABETH S.BISER 4:,i..
Secretary e'
DOUGLAS R.ANSEL NORTH CAROLINA
Interim Director 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:
• For a 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 of one 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
LEWIS—BRADY BUILDERS SUPPLY, INC
Responsible Official Name
MARIANNE L LEGGETT
Responsible Official Title:
AST VP
Email Address: Phone
MLEGGETT@LEWIS—BRADY.COM 910 628 7775
Mailing Address
PO BOX 188
City State Zip code
FAIRMONT NC 28340
__.______ .
DENorth Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
512 North Salisbury Street 11612 Mail Service Center I Raleigh,North Carolina 27699-1612
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DetarN.onto+F trammudo n. 919.707.9200

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 MARIANNE L LEGGETT
Delegated Party Title AST VP
Permit Number(s)
Ncr,140144
Email Address: MLEGGETT@LEWIS—BRADY.COM Phone [phone]
Mailing Address
PO BOX 1RR
City FAIRMONT State NC Zip code 28340
Signature of Delegated Party
indicating acceptance of JcV,.v,,,,--,
Signatory Authority: ✓✓✓��'
Date 8-16-2023
Delegated Party Name CHARLES WILCOX
Delegated Party Title CONCRETE PLANT MANAGER
Permit Number(s) NCG140344
Email Address: [e-mail] Phone [phone]
Mailing Address PO BOX 188
City FAIRMONT State NC Zip code 28340
Signature of Delegated Party Oltak
indicating acceptance of (dt-LE
Signatory Authority:
Date 8-16-2023
Delegated Party Name STEVE LEWIS
Delegated Party Title AST VP
Permit Number(s) NCG140344
Email Address: LEWISBRADY1945@GMAIL-COM Phone [phone]
Mailing Address PO BOX 188
City FAIRMONT State NC Zip code 28340
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date 08-16-2023
Stormwater Permit Delegation of Signatory Authority Form
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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, MARIANNE L LEGGETT (printed name),
have the authority to enter into this Agreement for
LEWIS-BRADY BUILDERS SUPPLY INC
(Owner/Organization Name).
I request that the DEMLR 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 NCDEQ's
electronic document systems.
By submitting this application,I,c\NQl1G.YlrVi Let-Q-A (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
ti.aivo•-k LQQ4J01---
Responsible Official Signatur/
Title Date
Stormwater Permit Delegation of Signatory Authority Form
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