NCG140347_SW Permit DOSA_20220714

NC Department of Environmental Quality
.T Division of Energy, Mineral and Land Resources
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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/whore 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
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:
NCG140347
Responsible 'Official Title: '
Vice President/General Manager
Email Address:
jason. b[[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
The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name: Daniel Lentz
Delegated Party.Titie. Area Safety & Environmental Mama er —_
Delegated Parry Organization: Thomas Concrete of Carolinas, Inc. _
<EMSH Address; [e-mail]1 Phone: [phone]
Mailing Addiress: 3701 N Graham St _ — — — _ _ —
'City: - Char State: NC Zip: 28206
Signature'of Delegated Party indicating
acceptance of Signatory Authority _.L—
_Delegated Party Name TSherwood Turner
Delegated Party Title: Area Operations Manager—
Deldgated Party Organization: Thomas Concrete of Carolinas, rInc. _ —
Emall Address: Sherwood Tumer@thomasconcrete coral Phone: [phone]
'Maiting,Address. 3733 National Dr #124 _ _
(city- PRIPinh State: TC TZiP 117612
Signature of Delegated Party indicating I I
P acceptance of $ignatpry Authority, —
a
Lpate. 1
Delegated Party Name, _ _ Zachary Garlick — — — —
Delegat�d °Party Title _ Engineering Technician
t _ — - — — — —
Delegated Parry Organization: SynTerra Corporation _ _ —
EmaiFAd'dress; [phone]
ze�arlic�synterracorp.com TPhone:
Jvlailirfg Address: 511 Keisler Dr #102
City: Cary State: rNC ZiP:�27518
Signaature ofDelegatedNParty indicating
acceptance of Signatory Authority:
Orate:
DeIbgated.Party Natne:—
D'elegat;rd PartyTitle_
Email.Address:
MWCiling Address
Signature of Delegated Party indicating
acceptance of Signatorys Authority: —
Date..
— — —TL Phonea — — —a
t State: rzip:
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,elegied 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 State: , NC Zipi E 27612
�. _.
�Sgnatureof Delegated Party indica(isg ,
adceptance of SignWry;Authonly
Date: ' 7/14/202
peJggated PartyNrne
Zachary Garlick
i7e1e6ated�Paiyite
Engineering Technician
r Delegated Pa�zation
SynTerra Corporation
Email Address
zgariick@synterracorp,comPhone:'
[phone]
Tailing Addressor
511 Keisler Dr #102
Cary
tole...
NC
Z'i . 27518
Slgnaiureofr©el+'gat-d Party indicating
accept ,race �f'Sig�r�aiory.Authority:. -"
c
Delegated PaGty�Ne;; , _�
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_ :
Delegated Party Title:
Daniel Lentz
Area Safety & Environmental Manager
Delegated Party Organization: _
Email Address:
Thomas Concrete of Carolinas, Inc.
Danny.lentz@thomascon_cr_ete_.c_ om Phone: [phone]
3701 N Graham St
Mailing Address:
City:
Charlotte
I State: INC
I Zip:
128206
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Parry Name:
Sherwood Turner
Delegated Party 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
State:INC
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]
I Phone: [phone]
Mailing Address:
511 Keisler Dr #102
City:
Cary
I State:
INC
I Zip:
127518
Signature of Delegated Party indicating
acceptance of Signatory Authority:)
Date:
Delegated 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:
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 BI th (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 work 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. i
Responsible (5 ial Signature
Vice President/General Manager [ l
Title Dat
Stormwater Permit Delegation of Signatory Authority Form
Page 3