NCG140466_SW Permit DOSA_20220714

xr NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CARO€.INA
�nvira�rmancar qu�ury
Stormwater Permit Delegation of Signature Authority Ferro
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.
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: ,
Thomas Concrete of Carolinas, Inc.
Permit Number:
NCG140466
Responsible official Title:..
Vice President/General Manager
Email Address:
'[e-mail]
Phone: [phone]
Mailing Address:
3733 National Dr #124
City:
Raleigh
state:
NC
zip:.
27612
Stormwater delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority .
-t> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name: _ Daniel Lentz
Deteg�ted Party Title: Area Safety & Environmental Manager _ - - -
Delegated Party Organization: Thomas Concrete of Carolinas, Inc. - - -
E lddress: [e-mail] Phone: [phone]
- - - - - - - - - - -
Wiling Address: 3701 N Graham St
City: lCharlotte State: rNC 1 Zip: 28206
Signature of Delegated -Party indicating y�
acc:eptanm'6f Signatory Authority --tom--�'"G�..—� 7
°Date. - - _ - _-zt' 2,Z... _
Delegated Orty Name. Sherwood Turner
r Del, 9ated Party, itle. _ Area Operations Manager__ - -
{ -=
Delegated Party Organizatioq: Thomas Concrete of Carolinas, Inc.
Email Address: Sherwood. Turner@thomasconcrete corn Phone: [phone]—
Mailing Address: 13733 National Dr #124
City Raleigh - - - - T State: �N�Zip: 127612
Sigrtature,of pelexgatOid party indicating
acceptanceld Signatory Authority^
Delegated PattyName; ]Zachary Garlick_
Delegated Party Title _ Engineering Technician - -
C Delegated Party Orgalnizat"ion: SynTe_rra Corporation
Email Address: _ zgarlic s nterracorp.com LPhone: [phone] -
Mailing ddrdss:` 511 Keisler Dr #102
City: Cary State: NC 1 Zip: 27518
Signature of Delegated Party indicating
acceptancekoi Signatory Authority: — — -- —
136te:
Delegated Patty Name:. f
Delegated Party 7itfe:
ti
°D`61 ated P Organization:
Email Address:-
' Mailing`Address: _ _ _ _
city: - -- - -- ' - State: i i Zip:
%gne'ture of Delegated Party indicating
acceptdnce of Signatory Authority -
Date: - -
Stormwater Permit Delegation of Signatory Authority Form
Page 2

A. Persons to Receive Signatory Authority
The sianatures of the persons listed below indicates their acceptance of signatory authorlty.
D,eleg4ed Party IVaume. Daniel Lentz
nelegaei Payfiitle Area Safety & Environmental Manager
V.
Uel�gated Paf`,Orgariz"tioD: Thomas Concrete of Carolinas, Inc.
[e-mail] Pho (704 201-6776
,tt1ail Address: rla
Mailing Address.' 3701 N Graham St
Cyr, Charlotte Stake °=,` NC Z!p 28206
tSnature of beisgated ParCyi d(aing
;seceptaricoSigfatary Authnty,,
l]'ate
D'elegatdPName;P Sherwood Turner
Delegated Party'Title Area Operations Manager
4elegated Party Organ'iz'��iora:' Thomas Concrete of Carolinas, Inc.
,Email Address d ° ' m [e-mail] Piloe„'' [phone]
3733 National Dr #124
Mailing Adc�r,�ess; °� meµ:
;Raleigh Stafe: , NC Zipi E 27612
�. _.
�Sgnatureof Delegated Party indica(isg ,
adceptance of SignWry;Authonly
Date: ' 7/14/202
peJggated PartyNrne
Zachary Garlick
i7eiegatedPaiyite
Engineering Technician
r Delegated Part+Organzation
SynTerra Corporation
Email Address .':
zgariick@synterracorp,comPhone:'
[phone]
Tailing Addressor
511 Keisler Dr #102
Cary
NC
Zi -27518
Slgnaiureofr©el+�gat�d, Party indicating ,:
accept,race�f'Sig�r�aiory .Authority: . ._
Datec
Delegated PaGty�Ne;; , _�
Ill
iture. of Delersgated P
ptance of Signatory
Stormwater Permit Delegation of Signatory Authority Form
Page 2

A. Persons to Receive Signatory Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name: Daniel Lentz
Delegated Party Title: Area Safety & Environmental Manager
Delegated Party Organization: Thomas Concrete of Carolinas, Inc.
Email Address: [e-mail] Phone: [phone]
Mailing Address: 3701 N Graham St
City: Charlotte I State: INC I Zip: 28206
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date
Delegated Party Name: Sherwood Turner
Delegated Party Title: Area Operations Manager
Delegated Party Organization: Thomas Concrete of Carolinas, Inc.
Email Address: [e-mail] Phone: [phone]
I Mailing Address: 3733 National Dr #124 _
- ----- --
City: Raleigh State: _]NC Zip: 27612
Signature of Delegated Parry indicating
acceptance of Signatory Authority:
, Date:
Delegated Party Name:
Zachary Garlick
Delegated Party Title:
Engineering Technician
Delegated Party Organization:
SynTerra Corporation
! Email Address:
[e-mail]
Phone:
[phone]
Mailing Address:
511 Keisler Dr #102
City:
Ca
State:
NC
Zip_
27518
i Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
`7
Delegated Party Name:
Delegated Party Title:
Delegated Party_ Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip;
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, Jason Blyth _ (printed name),
have the authority to enter into this Agreement for
Thomas Concrete of Carolinas, 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 worts attfor my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, Jason Blyth (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official. h
I-- �/' /'
ResponsT Official Signature
Vice President/General Manager /
Title Da e
Stormwater Permit Delegation of Signatory Authority Form
Page 3