NCG140418_SW Permit DOSA_20220714

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CAROLINAA
& w.froPmantatQuatiiy
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.
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 10 CFR 1.22,.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:::..
NCG140418
Responsible Official.Title
Vice President/General Mania er
Email Address:
[e-mail]
Phone: [phone]
Mailing Address:
3733 National Dr #124
city:
Raleigh
state.
NC . zip:
127612
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:
Daniel Lentz
Delegated Party Title
Area Safety & Environmental Manager
.�®legated„Party`Organi anon:"
Thomas Concrete of Carolinas, Inc.
Emeil AOdeess:
[e-mail] Phone:�[phone]
Mailing Address-
3701 N Graham St
ty:
Charlotte
I State:
NC
I Zip:
28206
Signature, of Delegated ;Party indicating
acce¢ta'rtce of Signatory Authority:
Date:
Delegate&Party Name.
Sherwood Turner
Delegated Party Title:
Area Operations Manager
_
,,Delegated Party"Organtzatiim:
Thomas Concrete of Carolinas, Inc.
Sherwood Tumer@thomasconcrete corn Phone:
3733 National Dr #124
Raleigh I State:
[phone]
INC I Zip: 127612
Email A4drdS9:
Mailing
_Addf6s's:
City:
Signure of Delegated Party, indicating
acceptance of. Signatory Authody
Hate:
Delegated`�P.arty Name:
Zachary Garlick_
i
_
Delegated Party Title- _
En ineering Technician
—..
Delegated Party bYganization:
SynTerra Corporation
'Emah Address:
[e-mail] i Phone.
1(336) 420-4853 ;
Mailing Address:
511 Keisler_ Dr #102
_State:
City:,
Ca
NC ZiP: 27518
,$ignatanii,6f Delegated.Party indicating
acceptance of Signatory Authority:
_
-- --- --
1
—'
Date --- - - - - -
Delegated Party Name -
Delegated Warty -Title: LT
I
Delegated Party Organization:
— -- 1 Phone: - --
Email;AddresS:
.Mailing Address:,
i ,�
Stater
Zip:
Signaturd of Delegated Party Indicating
acceptance of SignatoryAuthority-
- -
- -- J
Date_ - - - -
Y
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.
C]elQgated#Ftty;`Name; Daniel Lentz
Area Safety & Environmental Manager
Cpefeated Party`,Orgariion°' " "'Thomas Concrete of Carolinas, Inc.
Erjia[I Address [e-mail] Phones (704) 201-ro776
I;Matlmg"Address 13701 N Graham St
City " , ", Charlotte State: NC Zlp:: 213206
x.Delegated Pa[ty*me: "' 3''�A Sherwood Turner
Delegated Paity T[tle: ;, Area Operations Manager
D,elegake PartyOrganzatlori;,Thomas Concrete of Carolinas, Inc.
�1
Ema[l AareS [e-mail] PhOfte ;` [phone]
Ma[I[r�Atldress 3733 National Dr #124
CIY� r, ram' Raleigh 5� NC Zlp: 27612
Signature ()fr Delegatedf' a is frig'
acceptance of Signatoryu4� y
7/1
14/2022
D`.elegatetf I�arfy Name
Zachary Garlick
Delegated Pa,�lyfi[tle, .:
Engineering Technician
Delegated Par#y; Orgarizat[on:
SynTerra Corporation
mallA;eldress
[e-mail]
Phony ,; (336) 420-41353
Mall[ngAddfess
511 Kelsler Dr #102
G(t a ,. ;....
Ca
State ;
NC
�[p '
27518
$igriaure bftDe�eated Party [ndicatmg'..,
aeceptariee�of,S[gri�tory„�luthbnty
Date. " s3s :,
dress
s
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.
I Email Address:
[e-mail] Phone: [phone]
Mailing Address:
3701 N Graham St
City:
Charlotte
State:
NC
Zip:
28206
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date: -
Delegated Party Name:
Sherwood Turner
Delegated Parry Title:
Area Operations Manager
Delegated Party Organization:
Thomas Concrete of Carolinas, Inc.
Email Address:
[e-mail]
Phone:
_
[phone]
Mailing Address:
3733 National Dr #124
City:
Raleigh
I State:
INC
I Zip:
27612
Signature of Delegated Party 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:
Cary
State:
NC
Zip:
127518
Signature of Delegated Party indicating
acceptance of Signatory Authority:
346M �'J&Zte
Date:
% a
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 DEML.R Stormwater Program include the persons listed in Part A of this form
signatory authority for the above -named permit.
I acknowledge that 1, 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, 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.
Responsibl Official Signature
Vice Presi entlGeneral Manager ( vt
Title Date
Stormwater Permit delegation of Signatory Authority Form
Page 3