NCG140014_Delegation of Signature Authority_20260513

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ROY COOPER R�cc
Governor
MARY PENNY KELLEY
Secretary
WILLIAM E.TOBY VINSON.JR NORTH CAROLINA
Interim Director Environmental Qualify
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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
signature authority does not relieve the Permit Owner from the responsibility and comnliance 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.
• Fora 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: NCDEMLR Stormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity Foley Products Company,LLC DBA Foley Products A CMC Precast Business
Responsible Official Name Joe Sikes
Responsible Official Title: Regional OperationsManager
Email Address: ][e-mail] Phone [phone]
Mailing Address 1291 Hardigree Road
City Winder State GA Zip code 30680
D E Q�� North Carolina Department of Environmental Quality I Divhbn of Energy.Mineral and land Resources
512 North Salisbury Street 11612 Mail Service Center I Raleigh,North Carolina 27699-1612
+� •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 ifyou need more space.
Delegated Party Name Charles Piwowarski
Delegated Party Title Environmental Compliance Manager
PermitNumber(s) NCG140014
Email Address: [e-mail] Phone [phone]
MailingAddress 208 Jefferson Street
City Newnan State GA Zip code 30263
Signature of Delegated Party
indicating acceptance of
Signatory Authority: 61 N",/
Date 4/8/202
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address: Phone
MailingAddress
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address: Phone
MailingAddress
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Stormwater Permit Delegation of Signatory Authority Form
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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, Joe Sikes (printed name),
have the authority to enter into this Agreement for
Foley Products Company,LLC
DBA Foley Products A CMC Precast Business (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
!� e e�l ctronic—lc ocument-sysl=ems. - - -- --— - - - -- — —-By submitting this application,I, Joe Sikes (printed name),have read,
understand,and accept the terms and conditions of the stormwaterpermit(s)for which I
am the Responsib icial.
onsible Official Signature
Regional Operations Manager t//mZ90CIS
Title Date =�
Stormwater Permit Delegation of Signatory Authority Form
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