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Home My WebLink AboutNCG140499_SW Permit DOSA_20220527sun . 3 NC Department of Environmental Quality s '- Division of Energy, Mineral and Land Resources NORTH CAROLINA Stormwater Permit Delegation of Signature Authority Form Directions are in red. => This form shall be used to delegate signature authority from the permit Owner (Pennittee) 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. => 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 ani9ther 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. Organization Name: Responsible Official Name: Concrete Supply Co., LLC Henry Batten Responsible Official Title: President Email Address: Henry.Batten@ConcreteSupplyCo.com "Phonc. 704-372-2930 Mailing Address: P.O. Box 5247 City: Charlotte State: NC "Zips 28299 Skw mwater Delegation of ire Aar Farm Page 1 V A. Persons to Receive Signatory Authority => The signatures of the persons listed below indicates their acceptance of signatory authority. Delegated Party Name_ Delegated Party Title: Johnie Alexander Environmental Manager _- Permit Number: See All Attached Email Address: Mailing Address: JMnie.AlexanderCConcmtesupplyco.com Phone: 704-372-2930 P.O. Box 5247 City. ----- - ChArOe I State: INC I ZIP: 128299 Signature of Delegated Party indicating acceptance of Signatory Authority: Date: Way 26, 22 Delegated Party Name: Delegated Party Title: Permit Number: Email Address: Mailing Address: Phone: State: I lip: City:' Signature of Delegated Party indicating acceptance of Signatory Authority: Date: Name: Delegated Party_T_ itle: Permit Number: Email Address: Mailing Address: City: Signature of Delegated Party indicating acceptance of Signatory Authority: Date: Delegated Party Name: Delegated Party Title: Permit Number: Email Address: Mailina Address: Phone: F State: I I Zip: Phone: City: State: Zip: Signature of Delegated Parry indicating acceptance of Signatory Authority: Date: Stormwater Permit Delegation of Signatory Authority Form Page 2 c 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, Henry Batten (printed name), have the authority to enter into this Agreement for Concrete Supply Co., LLC and its Subsidiaries (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, Henry Batten (printed name), have read, understand, and accept the terms and conditions of the stormwater permit(s) for which I am the Responsible Official. Signature President of Concrete Supply Co., LLC May 26, 2022 Title Date Stormwater Permit Delegation of Signatory Authority Form Page 3 B. Permit Information Include all stormwater permit currently held by the Owner (both Individual and General permits). ' Designate any applicable Facility Administrators for each permit. Attach additional pages if you need more space. Permit No. Facility Name Facility Address Facility Administrator(s) i# applicable) 140499 Pittsboro Johnie Alexander 140196 Aberdeen Johnie Alexander 140013 Albemarle Johnie Alexander 140246 Arrowood Johnie Alexander 140065 Boeing Johnie Alexander 140040 Concord Johnie Alexander 140053 Croft Johnie Alexander 140051 Dallas Johnie Alexander 140310 Durant Park Johnie Alexander 140039 Matthews Johnie Alexander 140133 Gastonia Main Johnie Alexander 140292 Greensboro #1 Johnie Alexander 140318 Greensboro#2 Johnie Alexander 140343 Hamlet Johnie Alexander 140342 Hatchery Rd Johnie Alexander 140044 Kannapolis Johnie Alexander 140143 King Johnie Alexander 140050 Kings Mtn Johnie Alexander 140046 Lincolnton Johnie Alexander 140339 Lowery St Johnie Alexander 140437 Mebane Johnie Alexander 140358 Mocksville Johnie Alexander 140241 Monroe Johnie Alexander 140335 Mooresville Johnie Alexander 140307 Morrisville Johnie Alexander 140012 N. Mt. Airy Johnie Alexander 140041 North Johnie Alexander 140312 Reames Johnie Alexander SbmwrAff Beda ric Rep03V Ramon Fain Page 2 B. Permit Information = Include all stormwater permit currently held by the Owner (both Individual and General permits). ` Designate any applicable Facility Administrators for each permit, Attach additional pages if you need more space. ..* Permit No. Facility Name Facility Address Facility Administrator(s) d a licable 140049 Salisbury Johnie Alexander 140050 Shelby Johnie Alexander 140043 South Johnie Alexander 140208 Statesville Johnie Alexander 140305 Stokesdale Johnie Alexander 140066 Thomasville Johnie Alexander 140038 Tri-City Concrete Johnie Alexander 140054 West Johnie Alexander 140392 CCC -Winston Salem Johnie Alexander 140453 Fletcher Johnie Alexander 140398 Marshall Johnie Alexander 140382 Swannanoa Johnie Alexander SkiffnwaSer Bechu= Repw" Re�xi Farm Page 2