NCG160177_SW Permit DOSA_20221221

NC Department of Environmonial Quality
Division of Energy, Mineral and Land Resources
(.`nV1rW)111e11w1 oiluri!y
�ormi wa er Paydt Ddegafion of Sigriature Authority term
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 DIa1Vl R 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 scrch 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 he 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 shalt be a general partner or the
proprietor, respectively; or
o For a municipality, State, Federal, or other public agency, the Responsible Official shall be either a
principal executive officer [City/County Managet] 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 Asphalt Emulsion Industries, LLC
Responsible Official Name: 1. Paul Tarsovich
Responsible Official Title:
V
Email Address:
..... ...... ..__ _..._
Paul tarsovich@slurrypavers com
....._.
j Phone:
(804-264-0707
Mailing Address:
3617 Nine Mile Road
City:
Richmond
state:
VA dip: I23223
Stormwater Delegation of Signature Authority Form
Page I

A. Persons to Receive Signatory Authority
> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name: Ken Olsen
- - - -.......... ............... ... ..... ._... ......... -
Delegated Party Title: Safety Director
----
Permit Number: NCG160177
........................................
Email Address: [e-mail] Phone: [phone]
........
- -
Mailing Address: 3723 Nlne Mile Road
City: Richmond State. VA Zip: 23223
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address
Phone:
-----..._. .........
Mailing Address:
- --
- -- -
-
J
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
- - -
.....
..... ......... ._ -- --- - -- -- - -- - -
Delegated Party Title:
-... .. - ---
- .... ... ... ... ............ ..... _.... ------ ---- -- --- - -
Permit Number:
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, Paul Tarsovich
have the authority to enter into this Agreement for
alt Emulsion Industries, LLC
(Owner/Organization Name).
(printed 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, 1, Paul Tarsovich (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Responsible Official Signature
Title
Vice President
W
Stormwater Permit Delegation of Signatory Authority Form
Page 3

@� NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
rtORTII CARD_€NA
1`1i00> nrtcnt'l (irl fify
Storewater P.DWIR SubmUtelr Change Request Form
This form is for adding or updating the Submitter User(s). Submitter(s) must have
signatory authority for the permit in order to have Subrrritter privileges in eDMR.
A. Owner Information
This form must be completed by a Responsible Official who meets the legal signature
authority requirements in 40 CFR 122.22 or a person who has been delegated
signature authority to act on behalf of the Ow;3er.
Owner/organization Name: Asphalt Emulsion Industries, LLC
Responsible official Name: Paul Tarsovich
- ---------- -- --
Tine: Vice President
1.eDMR User ID:
Email Address: Paui.Tarsovich@slurrypavers,com Phone [phone]
Mailing Address: 3617 Nine Mile Road
.............. .
City: Richmond State VA zip:�23223
1 . Activate New Submitter or Update Existing User
=> Please complete the Submitter User Detail on page 2 for the individuals who will need
Submitter permission or to update Submitter details, such as adding additional permits,
to an existing user. Submitter permissions can only be assigned by the Stormwater
eDMR Administrator. JVore: The ]Responsible Official and Facility Administrator
can deactivate or delete eDMR user perrissions for any individual within its
organization, including Submitter permissions.
� In addition to the User Details, please specify the permit(s) that each user will be
associated with for eDMR submittal. Should additional space be needed for user and/
or permits, please make additional copies for the Submitter User Details page and
complete as needed.
eDMR Submitter Change Request Form
Page 1

Submitter User Details
Permit No. (s):
NCG1 60177 -
-------------7 7F-
First Name:
Ken
Middle Name:
Last Name:
Olsen
Phone Number:
804-716-7928
Email:
[e-mail]
User ID:
(Assigned by NGDWR eOMR Administrator)
Select Request
Type:
nvAdd User Permission
12/1/2022
Add/Update User Perniission as of (Date):
Update User Permission
Submitter User Details
First Name:
Middle Name:
Last Name:
Phone Number:
Email:
User ID:
(Assigned by NCDWR eDMR Administrator)
Select Request
Type:
f—]Add User Permission
Add/Update User Permission as of (Date):
E]Update User Permission
Submitter User Details
First Name:
Middle Name:
Last Name -
Phone Number:
Email:
User ID:
(Assigned by NCDWR eDMR Administrator)
Select Request
Type:
E]Add User Permission
Add/Update User Perrn�ssion as of (Date):
OUpdate User Permission
aOMRSubmittesChange Request Form
Page

C. Electronic Signature Agreement Conditions
To receive and accept the required electronic signature credential, consisting of a User 1D and
password, issued by the North Carolina Division of Water Resources (NCDEQ) in order to sign
electronic documents submitted to NCDEQ's Electronic Document Systems and to receive
electronic documents from NCDEQ's systems;
The Responsible Official and Submitter(s) (if applicable) named in this form do herby:
1. Understand that this Electronic Signature Agreement requires me, to submit electronic
documents to NCDEQ's approved eDMR system under the authorized program in lieu of paper
submissions.
2. Understand that this Electronic Signature Agreement requires me to accept electronic
transmissions, in lieu of paper transmissions of all permits, permit modifications, authorizations
to construct, and any other correspondence related to reviewing and processing permits from
NCDEQ. This authorization will not become effective until NCDEQ establishes a system for
processing electronic documents; I am notified in writing from NCDEQ that use of the electronic
systems has officially been initiated; and North Carolina rules and statutes are changed to allow
the implementation of electronic submittal and acceptance of documents.
Understand that this Electronic Signature Agreement requires me to submit electronic all
necessary information for processing of NPDES application including information for renewal of
existing permits, modification to existing permits, and applications for new discharge permits.
The submittals may include all necessary applications and supporting documentation to
NCDEQ's approved system for electronic submittals in lieu of paper submissions. This
authorization will not become effective until NCDEQ establishes a system for processing
electronic documents; I am notified in writing from NCDEQ that use of the electronic systems
has officially been initiated; and North Carolina rules and statutes are changed to allow the
implementation of electronic submittal and acceptance of documents.
4. Understand that this Electronic Signature Agreement requires me to accept electronic
submissions, in lieu of paper submissions, of all Notices of Deficiency, Notices of Violation, Civil
Penalty Assessments, and any other correspondence related to compliance with federal and
state water quality laws and regulations that might be sent by NCDEQ. This authorization will
not become effective until NCDEQ establishes a system for processing electronic documents; I
am notified in writing from NCDEQ that use of the electronic systems has officially been
initiated; and North Carolina rules and statutes are changed to allow the implementation of
electronic submittal and acceptance of documents.
5. Agree to protect both the electronic signature credential, consisting of my User ID and
password, and security questions and answers, from compromise and from use by anyone
except me. Specifically, I agree to maintain the secrecy of my electronic signature credential
and security questions and answers; I will not divulge or delegate my credential or security
questions and answers to any other individual; I will not store my credential or security
questions and answers in an unprotected location; and I will not allow my electronic signature
credential or security questions and answers to be written into computer scripts to achieve
automated log -in.
Understand and agree that I will be held as legally bound, obligated, and responsible for the use
of my electronic signature as I would be using my hand-written signature.
7. Understand that I will be informed through my registered email address whenever my User I❑
or password has been modified.
eDMR Submitter Change Request Form
Page 3

8. Understand that eDMR reports the last date my User ID and password were used immediately
after successfully logging into eDMR.
9. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMlncder�r�gov as
soon as possible, but no later than 24 hours, after suspecting or determining that my User ID
and/or password have become lost, stolen or otherwise compromised.
10. Agree that I will review the contents of all electronic submissions prior to submission.
11. Understand that I will automatically receive an email receipt at my registered email address
from the NCDEQ's SW-eDMR system for any submission that contains a valid electronic
signature, identifying the document received, the signatory, and the date and time of receipt.
12. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMR_@_Iicden�-.gov if I
do not receive an email receipt as specified above within five (5) business days for any
electronically signed submission using my credentials.
13. Agree that if I received an email notification for an activity that I do not believe that I performed,
I will notify the NCDDEQ SW-eDMR Administrator via email at SW-eDMR(eijcdenr.cdov as soon
as possible, but no later than 24 hours, after receipt.
14. Agree to report, within 24 hours of discovery, any evidence of discrepancy between any
electronic document I have signed and submitted and what the NCDEQ eDMR has received
from me by contacting the NCDEQ SW-eDMR Administrator via email at SW-
�DM�-��ncden-.cw.
15. Understand that the NCDEQ eDMR's system will automatically reject any electronic document
submitted without a valid electronic signature if such signature is required.
16. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMR(c�ncdenr.aov
within ten working days if my duties change and I no longer need to interact with eDMR on
behalf of my organization,
1T Agree to notify the NCDEQ SW-eDMR Administrator via email at [e-mail] if I
cease to represent the regulated entity specified above as signatory of that organization's
electronic submissions as soon as this change in relationship occurs.
18. Understand that the NCDEQ may contact the Organization's Responsible Official, who signs
below to authorize me as a signatory for the Owner/Organization, in order to verify my identity.
19. Agree to retain a copy of this signed agreement as long as I continue to represent the regulated
entity specified above as signatory of the Organization's electronic submissions,
20. Certify that I have the authority to enter into this Agreement on behalf of the Organization
identified above, and I am a signatory authorized to represent that Organization, and I am able
to sign and submit reports and other information on behalf of that Organization in the capacity
required by statute and/or regulation.
eDMR Submitter Change Request Form
Page 4.

D. 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.
I
Paul Tarsovich
(printed name), have the authority to enter into
this Agreement for Asphalt Emulsion Industries, LLC
(Owner/Organization Name).
request the NCDEQ grant the Submitter(s) named in Part B of this form an electronic signature
credential to submit and accept documents electronically on behalf of my organization.
acknowledge that 1, and the individual(s) named in Part B of this form, work at/for my
organization and have authority to submit and accept electronic documents and act as a
signatory for purposes of the NCDEQ's electronic document systems.
By submitting this application, I, Paul Tarsovich (printed name),
have read, understand, and accept the terms and conditions of this Electronic Signature
Agreement. I certify under penalty of law that I have personally examined and am familiar with
the information submitted in this application and all attachments and that, based on my inquiry
of those persons immediately responsible for obtaining the information contained in the
application, 1 believe that the information is true, accurate and complete. I am aware that there
are significant penalties for submitting false information, including the possibility of fine and
imprisonment,
Responsible Official Signature
Title
Vice President
eDMR Submitter Change Request Form
Page 5
Id �n ova
Date

E. Submitter Signature
_* Provide a separate page of Part E for each Sumitter User listed in Part B.
The Submitter (electronic signature applicant) is a user other than the Responsible Official who
submits this agreement to request to sign reports electronically. The Submitter is given
signatory authority by an individual identified as the Responsible Official by the
Owner/Organization to sign reports and other information and to accept electronic documents.
1 Ken Olsen (printed name), am authorized by the
Responsible Official named in this document, who has the authority under the applicable
standards, to enter into this agreement for Asphalt Emulsion Industries, LL C (Owner/
Organization Name).
By submitting this application, I,
Ken Olsen
(printed name),
have read, understand, and accept the terms and conditions of this Electronic Signature
Agreement. I certify under penalty of law that I have personally examined and am familiar with
the information submitted in this application and all attachments and that, based on my inquiry
of those persons immediately responsible for obtaining the information contained in the
application, I believe that the information is true, accurate and complete. I am aware that there
are significant penalties for submitting false information, including the possibility of fine and
imprisonment.
Submitter Signature
Title
Date ) "26 A)),—
Submit the completed tarmwater eDMR Submitter Change Request Form in hard copy ,.,.....,....,.,_
with oriclinal signatures to:
DEMLR Stormwater Program eDMR
Attn: Stormwater eDMR Administrator
1612 Mail Service Center
Raleigh, NC 27699-1612
eDMR Submitter Change Request Form
Page 6