NCG140537_Signature Authority Form_20240312

Duly Authorized Representative(DAR) Designation Form
Corporate Responsible Officials(RO's) have the option to designate a Duly Authorized Representative
(DAR)to sign regulatory documents(e.g., applications, routine reports,certifications, DRMs etc.)
Company Name:-Smyrna Ready Mix Concrete
I hereby certify that I meet the criteria of a Responsible Official for the subject facility in accordance with
the above referenced regulations. Specifically, I Jeff Hollingshead .
(print name of Corporate Responsible Official)
Check One
❑✓ am an officer of the Corporation. My title is: CEO
❑✓ perform policy or decision-making functions similar to that of an officer of the
corporation.
Describe: Permit Signatory Authority/ DMR Signatory Authority
I hereby designate the following individual as a DAR to act in my stead in matters pertaining to
ADEM permitting.-
Name: Jacquelyn "Danielle" Pudvah Title:Chief Sustainability Officer
Address: 5379 Capital Circle SW, Tallahassee, FL 32305
Phone: [phone] Email: [e-mail]
DAR Criteria Questions
❑✓ Yes ❑No Is the above-named DAR responsible for overall operation of one or more
manufacturing,production, or operating facilities employing more than 250
persons or having gross annual sales or expenditures exceeding$25 million(in
1980 dollars)?
❑✓ Yes ❑No Has authority to sign documents been assigned or delegated to the above named
DAR in accordance with corporate procedures?
Please note that if you answered"No"to both of the above questions, the individual does not meet the criteria to be a DAR.
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6L�C, nature of Cor ate Respon rcia0 (Date)
Last Revised: 12/12/2019