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HomeMy WebLinkAboutNCG200545_SW Permit DOSA_20230717 ROY COOPER Governor i= I ELIZABETH S.BISER s f -x` Secretary 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 signature authority 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 Duke Energy Progress,LLC; Duke Energy Carolinas,LLC Responsible Official Name Jessica Bednarcik Responsible Official Title: Senior Vice President, EHS&CCP Email Address: Phone Jessica.Bednarcik@duke-energy.com 4-o4. 3g2-gl(x Mailing Address Mail Code EC13K,PO Box 1006 City State Zip code Charlotte NC 28201 DE-4 North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources �/ 512 North Salisbury Street 11612 Mail Service Center I Raleigh,North Carolina 27699-1612 bwrImatt aw++^d \ 919.707.9200 B. Responsible Official Signature The Responsible Official,as identified in accordance with 40 CFR 122.22, is the appropriate individual with the authorityto sign and submit reports for the organization. As the Responsible Official,I, Jessica Bednarcik _ (printed name), have the authorityto enter into this Agreement for Duke Energy Carolinas,LLC (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, Jessica Bednarcik (printed name),have read, understand,and accept the terms and conditions of the stormwater permit(s)for which I am the Responsible Official. Re onsible ficial Signature Senior Vice President,EHS&CCP (a 1 2°2-3 Title Date Stormwater Permit Delegation of SignatoryAuthority Form Page 3