NCG140350_SW Permit DOSA_20220714

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NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
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Stormwater Permit Delegation of Signature Authority Form
©inactions are in red.
This form shalt 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 D'MLR 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:
NCG140350
Responsible Official Title:
Vice President/General Manager
Emai! Address:.
[e-mail]
:Phan:
[phone]
Mailing Address:
3733 National Dr #124
City:
Raleigh ]S�NCzip:,
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: (Zachary Garlick
Delegated -Party -Title: jEngineering Technician
Delegated Party Organization: SynTerra Corporation
Email Address: �[e-mail] I Phone: I(336) 420-4853
Mailing Address: 511 Keisler Dr #102
City: Ca State: NC Zip: 27518
S� ignaturo of Delegated Party indicating
I acceptance of Signalory Authority:
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority;
Date
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Mailing Address:
City:
Signature of Delogated Party Indicating
acceptance of Signatory Authority:
Date
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date.
Phone:
State: I. Zip:
Phone: I
State: I I Zip:
Phone:
State: I LID:
Stormwater Permit Delegation of Signatory Authority Form
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B. Responsible Official Signature
The Responsible Official, as identified in acgordance with 40 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, 1, 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.
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 aWthe esponsible Official.
J{
Respon6iOfficial Signature' 6679
Vice President/General Manager Lv�-
Title [)at
Stormwater Permit Delegation of Signatory Authority Form
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