NCG140382_SW Permit DOSA_20221221

Fp' STAT.� r.
:<<r" NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
N 0 R r}.{ ,CAROUNA
en vi.rwomanrat Quality
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 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.
Organization Name:
Carolina Ready Mix and Builders Supply, LLC
Responsible Official Name:
Henry Batten
Responsible Official Title:
President
Email Address:
[e-mail]
Phone:
704-372-2930
Mailing Address:
PO Box 5247
City:
Charlotte
State:
NC
I Zip:
28299
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
-7> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Gary Kllker
Delegated Party Title:
operations Manager
Permit Number:
NCG140382
Email Address:
[e-mail]
I Phone:
868-686-3040
Mailing Address:
606 Old US 70
City:
Swa nanoa
I State:
NC
I Zip:
28778
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
12/12/202
Delegated Party Name:
Melissa Tobias
Delegated Party Title:
office Manager
Permit Number:
NCG140382
Email Address:
[e-mail]
Phone:
828-686-3040
Mailing Address:
606 Old US 70
City:
Swannanoa
State:
NC
I Zip:
28778
Signature of Delegated Party indicating
acceptance of Signatory Authority:
�-&'LC-L�j1,cc�
Date:
12/12/2022
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:
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

NC Division of Energy.. Mineral and Land Resources
NPDES Stormwater Permit Summary
NC DEMLR has the following information in our Permit Database for ,your „permit as of 12/12/2022.
Permit Number: NCG140382 Permit Status: Active
Permit Type: Ready Mix Concrete Stormwater/Wastewater Discharge COC
Facility Name: Carolina Ready Mix & Builders Supply, LLC
Facility Addressl: 608 Old US 70
Facility Address2:
City, State & Zip: Swannanoa, NC 28778
Owner Information Details:
Owner Affiliation: Henry Batten Title:
Addressl: PO Box 5247
Address2:
City, State & Zip: Charlotte, NC 28299
Work Phone: [phone] Fax:
Email Address: henry. [e-mail]
***, Perm t Annual Fe' e—
Billing Month: August
Invoice Number Invoice Date Invoice Due DateInvoice Amount Invoice Status
;owner Contact Persons)
Contact Name Title Address Phone Fax Email
Fac�E ty Contact Persons)
Contact Name Title Address Phone Fax Email
Johnie Alexander PO Box 5247, Charlotte, NC 28299 704-372-2930 johnie.alexander@c
oncretesupplyco.co
m
Pdr'.m it Coini:act Person`(s)
Contact Name Title Address Phonq Fax Email
Johnie Alexander PO Box 5247, Charlotte, NC 28299 704-372-2930 johnie.alexander@c
oncretesupplyco.co
m
12/12/2022 Page 1

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Summary
NC DEMLR has the following information in our Permit Database for your permit as of 12/12/2022
Perm t B�ii n9 Cohtact(s)
Contact Name Title
Address
Phone Fax
Email
Johnie Alexander
PO Box 5247, Charlotte, NC 28299
704-372-2930
johnie.alexander@c
oticretesupplyco.co
m
Persons with (-) Deiegated;Sgnato' Au hor�t
Tyae Contact Name Title
Address
Phone Fax
Email
Permit Johnie Alexander
PO Box 5247, Charlotte, NC
704-372-2930
johnie.alexander@concr
28299
etesuppiyco.com
Pe�rson(s) with, Elect anrc Signa,ei�te Aq.t.orn
TVDe Contact Name Title Address Phone Fax Email
JJ
Outalis ,
Outfall #: 001 Outfall Description: drains to catch basin at side of propert
Outfall Lattitude: 35.602780 Outfall Longitude:-82.384170 Represented by Outfall:
Stormwater: 100
Basin
French Broad
Industrial:
Waterbody Name
Swannanoa River
Stream Waterbody
Index Number Classification
6-78
re
12/12/2022 Page 2

B. Responsible Official Signature
The Responsible Official, as identified n 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, Henry Battpiu� (printed name),
have the authority to enter into this Agreement for
Carolina Ready Mix and Builders Supply, LLC (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 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, I, Henry Batt Cel (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
nsible Official Signature
President
Title
t Z r -? Czz
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3