NCG160223_SW Permit DOSA_20220325

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental Quality
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
=> 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 for permit
compliance.
z::::> The permit Owner is 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].
Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
Permittee:
Permit Number:
Responsible Official Title:
Email Address:
Mailing Address:
City:
FIBRECRETE PRESERVATION TECHNOLOGIES, INC.
NCG 160223
PRESIDENT
[e-mail]
131 ST. JAMES WAY
MOUNT AIRY
Phone: , 336-786-8244
State: NC Zip_ 27030
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
=> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name: KEITH MILLER
Delegated Party Title: OPERATIONS MANAGER
Delegated Party Organization: FIBRECRETE PRESERVATION TECHNOLOGIES, INC.
Email Address: [e-mail] Phone: [phone]
Mailing Address: 401 OLD HIGHWAY 52 SOUTH
City' MOUNT AIRY State: NC Zip: 27030
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date: -C_ I k
Delegated Party Name: KENNY CAVINESS
Delegated Party Title: EH&S MANAGER
Delegated.Party Organization: FIBRECRETE PRESERVATION TECHNOLOGIES, INC.
Email Address: [e-mail] Phone: [phone]
Mailing Address: 131 ST. JAMES WAY
City: MOUNT AIRY State: NC Zip: 27030
Signature of Delegated Party indicating r
acceptance of Signatory Authority:
Date: 3 .�-72-
uelegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address; Phone;
Mailing Address:
City: State:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Nam€:
Title:
Email Address: Phone:
Mailing Address:
City: State:
Signature of Delegated Party indicating zip'
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of Signatory Authority Form
Page 2
Scanned with CamScanner

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, BARTHOLOMEW S. PHARR
have the authority to enter into this Agreement for
FIBRECRETE PRESERVATION TECHNOLOGIES, INC. (Owner/Organization Name).
(printed 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, BARTHOLOMEW S. PHARR (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Resoonsible Official./'
J-
Responsible Official Signature
PRESIDENT
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3