NCG070109_SW Permit DOSA_20240418 (2)

ROY COOPER -... 1�'
Governor j
ELIZABETH S.BISER
Secretory }v r
4100
DOUGLAS R.ANSEL NORTH CAROLINA
Interim Director Environmental Quality
Stormwater Delegation of Signature Authority Form (DOSA)
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
t• ' -uthox_ity does not relieve the Permit Owner from the responsibility and compliance for
permit compliance.
Permit Owner: 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].
Please mail the DOSA Form with original wet signatures to: NCDEMLRStormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity
Johnson Concrete Products
Responsible Official Name
Jody Wall
Responsible Official Title:
Executive Vice President
Email Address: Ph
[e-mail] + one I 704 636-5231
Mailing Address P@ Box 1037
City I State I I Zip code I
Salisbury NC 28145
-45 North Carolina Department of Environmental Quality Division of Energy.Mineral and Land Resources
v ) S12 North Salisbury Street i 1617.Mail Service Center I Raleigh.North Carolina 27699 1612
,xj 4Fw1ASIlYy1
°.0\ o 919.707.9200

A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Attach additional pages if you need more space.
Delegated Party Name Jody Wall
Delegated Party Title Executive Vice President
Permit Number(s) NCG070046, NCG070109, NCG070111, NCG070212
Email Address: [e-mail] I Phone [phone]
Mailing Address PO Box 1037
City Salisbury State NC Zip code I 28145
Signature of Delegated Party
indicating acceptance of
Signatory Authority: A J�
Date
Delegated Party Name Tim Agner
Delegated Party Title Manager of Engineering Services
Permit Numbers) NCG070046, NCG070109, NCG070111, NCG070212
Email Address: [e-mail] Phone [phone]
Mailing Address PO Box 1037
City Salisbury State NC Zip code 28145
Signature of Delegated Party _
indicating acceptance of
Al
Signatory Authority:
Date
Delegated Party Name Joseph Konzelmann
Delegated Party Title Environmental Compliance Supervisor
Permit Number(s) NCG070046, NCG070109, NCG070111, NCG070212
Email Address: [e-mail] I Phone [phone]
Mailing Address PO Box 186
City Gold Hill State NC Zip code J 28071
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
/I7
Stormwater Permit Delegation of Signatory Authority Form
Page 2

E. Responsible Official Signature
This form must be completed with an original wet signature (not digital) [40 CFR 122.22]
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.
Jody Wall
(printed name), have the authority to enter
into
this Agreement for Johnson Concrete Products (Owner/Organization
Name).
I request the NCDEQ grant me and, if included in Part B of this form, the named User(s), an
electronic signature credential to submit and accept documents electronically on behalf of my
organization.
I acknowledge that I, and if included in Part B of this form, the named User(s), 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, Jody Wall (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.
kJ h=. V.P. 4,1 12-0
R spa ' le Official Signature Title Date
eDMR User ID
Stormwater Electronic Reporting Registration Form
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