NCG140453_SW Permit DOSA_20221221

��r iThTf ry
NC Department of Environmental Quality
µ
Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Errvfrrorrmenraf 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/whcm 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 4.0 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:
henry.batten@ can cretesupplyco.com
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
� The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Gary Kilker
Delegated Party Title:
Operations Manager
Permit Number:
NCG140453
Email Address:
[e-mail]
Phone: [phone]
Mailing Address:
606 Old US 70
City:
Sw nnanoa
State:
NC
I Zip: 28778
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
12112i2
Delegated Party Name:
Melissa Tobias
Delegated Party Title:
Office Manager
Permit Number:
NCG140453
Email Address:
[e-mail]
Phone:
828-686-3040
Mailing Address:
606 Old US 70
City:
Swannanoa
I State:
INC
I Zip: 28778
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
12/1212022
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 followina 'information in our Permit Database for your Vermit as of 12/12/2022.
Permit Number; NCG140453 Permit Status, Active
Permit Type: ReadV Mix Concrete Stormwater Wastewater Discharge COC
Facility Name: Carolina Ready Mix South Asheville Plant
Facility Addressl; 264 Mills Gap Rd
Facility Address2;
City, State & Zip: Fletcher, NC 28732
Owner Information Details:
Owner Name: Carolina Ready Mix & Buildings Supply LLC
Owner Type: Non -Government Owner Type Group: Organization
Owner Affiliation: Henry Batten Title:
Addressl: PO Box 5247
Address2:
City, State & Zip: Charlotte, NC 28299
Work Phone: [phone] Fax:
Email Address: [e-mail]
**',';ReTwrXtit"Ann [aC..Fee<Billing ***
Billing Month: ALaC
Invoice Number Invoice Date Invoice Due Date Invoice Amount Invoigg Status
Owner Contact P'�rson(s) ``
Contact Name Title Address Phone Fax Email
Facility Cattact "Person(s)
Contact -Name Tit
Add
Phone Fax
Email
Johnie Alexander
PO Box 5247, Charlotte, NC 28299
704-372-2930
johnie.alexander@c
oncretesupplyco.co
m
Permit, Contact" Persons)
Contact Name Ti le
Ad r ss
Phone 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 DFM,LR has the following information in our Permit Database for your permit as of 12/12/7022.
Persoo(s) wt h,Elett .' Signature Authority
Twe Contact Name Title Address Phone Fax Email
Outfall #: 001 Outfall Description: ,pipe outlet
Outfall Lattitude: 35,431390 Outfall Longitude:-82.478890
Stormwater: 100 % Industrial:
Basin Waterbody Name
French Broad Hoopers Creek
Represented by Outfall:
Stream
Index Number
6-57-19
Waterbody
Classification
C;Tr
12/12/2022 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, Henry Batte_v�
have the authority to enter into this Agreement for
Carolina Ready Mix and Buiiders Supply, 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.
1 acknowledge that I, and the persons :fisted 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 0,, (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
President
Title
le Official Signature
12-1,
Date
Stormwater Permit delegation of Signatory Authority Form
Page 3