NCG140125_SW Permit DOSA_20240920

:ram •-lf"f
4. .• -;, NC Department of Environmental Quality
t� Fes. T.
J�
4,71 ' Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental 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 Storm water 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 he 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: Chandler Concrete Company Inc.
Responsible Official Name: Ryan Foley
Responsible Official Title: Corporate Environmental Manager
Email Address: [e-mail] Phone: [phone]
Mailing Address: 1006 S. Church St.
City: Burlington State: NC Zip: 27215
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: Ryan Foley
Delegated Party Title: Environmental Manager
Permit Number: All DPD Team Concrete NCG140—,permits
Email Address: [e-mail] Phone: [phone]
Mailing Address: 1006 S.Church St.
City: Burlington State: NC Zip: 27215
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date: September 6,2024
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:
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, Ryan Foley (printed name),
have the authority to enter into this Agreement for
Chandler concrete company Inc. (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.
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, I, Ryan Foley (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Res !al Signature
Corporate Environmental Manager September 6,2024
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

,1 1•17"1, F ,1 1 ru n 11vr1 .r1•i4 1C �'
11•' LI iv 1' I 11- 13, 14,01
11 '■'11,1-111 11 ''''' 11 11, 1�1 11 n1 ,11J11Llhldl
1.11I 1 1 r1111 - --- III 11,1 I II L■'11 1111I 11 '1.1 Iiu.
NIrL 111'11 11 .II , 111 ' 111111 61,110,1 RI" '-r'1'0
11111 11E n� „ 11 1 •� 1 �,,1 � � .1 „11
1, 1 1• F1 111 1r ti 1' L II 1 ,,1„1'I „.11' 1 ,1 11 ill—IL .11 11,11 , 1, 11 4' I •, 11 I •1•UI • 11
1111,71 1 11 1 II,h111i.1
11I111'.:11i�'G1 1i 1�1 I 111 '111 'L i i i .I i111 '1i y1y r ,�1 11 fi 1,1 1,, l el, T' 1171111.7 1 IL?• 'm-11/1T 111
111E 1114i1C 111111111I1I 11 1 11 1' 111I 1 I 111 'ill 111111 1111 ■ 1 ' 111 ■ JI 011 U Jii111 .1UL11111111i
'1111,1111,1■
I 11 �" 111 h11 1 111'"fin
1'11 '. i111 If" 4111 1, 11'1'li •1 1 1•1191111 11 1 L'I 11 ' 1, IIII i'y 1,11 111 IW"1I11 HIi hi 1M11Ln
111,111,1 " "' h u11 7 11111 1 1 1 ,'UI:RJI
--- - - 1 1 11 TT4IA '1 •u 11
111II 11, ---- 1 m — 1J 1 .'
11Lr 7��' I
I!"1 1 '1 1■f' ': ,i 1 ' 1�' 1 1 • � 1 1 1 1 I �� ' 1 1 1 I'
1 111� 1