NCS000582_DOSA Form_20220812

+� NC Department of Environmental Quality
4m--' Division of Energy, Mineral and Land Resources
NORTIA CAROLINA
EnWr•nmen al Quality
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
a 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 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 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].
Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
Organization Name:
Ennis Flint
Responsible Official Name:
Randy Krahn
Responsible Official Title:
Plant Manager
Email Address:
[e-mail]
I Phone:
336-308-3843
Mailing Address:
201 Old Thomasville Rd
City:
High Point
I State:
NC
I Zip:
27260
RECSi V ED
l2 202?
DENR-LAND QUALM/
STGRf+l ATER PEP,4 K ING
Stormwater Delegation of Signature Authority Form
Page 1

B. Permit Information
=> Include all storm water permit currently held by the Owner (both Individual and General
permits). Designate any applicable users for each permit. Attach additional pages if you need
more space.
Permit No. Facility Name Facility Address Name of the User
if applicable)
NCS000582 Ennis Flint 201 Old Thomasville Rd, High Point, NC 27260 Tim Schwendeman
Stormwater Electronic Reporting Registration Form
Page 2

B. Understand that eDMR reports the last date my User ID and password were used immediately
after successfully logging into eDMR.
9. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMR(a),ncdenr.gov
as soon as possible, but no later than 24 hours, after suspecting or determining that my User
ID and/or password have become lost, stolen or otherwise compromised.
10. Agree that I will review the contents of all electronic submissions prior to submission.
11. Understand that I will automatically receive an email receipt at my registered email address
from the NCDEQ's SW-eDMR system for any submission that contains a valid electronic
signature, identifying the document received, the signatory, and the date and time of receipt.
12. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMR(a),ncdenr.gov if
I do not receive an email receipt as specified above within five (5) business days for any
electronically signed submission using my credentials.
13. Agree that if I received an email notification for an activity that I do not believe that I
performed, I will notify the NCDDEQ SW-eDMR Administrator via email at SW-
eDMR(a)ncdenr.gov as soon as possible, but no later than 24 hours, after receipt.
14. Agree to report, within 24 hours of discovery, any evidence of discrepancy between any
electronic document I have signed and submitted and what the NCDEQ eDMR has received
from me by contacting the NCDEQ SW-eDMR Administrator via email at
SW-eDMRancdenr.gov.
15. Understand that the NCDEQ eDMR's system will automatically reject any electronic document
submitted without a valid electronic signature if such signature is required.
16. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMR(a),ncdenr.gov
within ten working days if my duties change and I no longer need to interact with eDMR on
behalf of my organization.
17. Agree to notify the NCDEQ SW-eDMR Administrator via email at SW-eDMR(a)-ncdenr.gov if I
cease to represent the regulated entity specified above as signatory of that organization's
electronic submissions as soon as this change in relationship occurs.
18. Understand that the NCDEQ may contact the Organization's Responsible Official, who signs
below to authorize me as a signatory for the Owner/Organization, in order to verify my
identity.
19. Agree to retain a copy of this signed agreement as long as I continue to represent the
regulated entity specified above as signatory of the Organization's electronic submissions.
20. Certify that I have the authority to enter into this Agreement on behalf of the Organization
identified above, and I am a signatory authorized to represent that Organization, and I am
able to sign and submit reports and other information on behalf of that Organization in the
capacity required by statute and/or regulation.
Stormwater Electronic Reporting Registration Form
Page 5

A. Persons to Receive Signatory Authority
=> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Tim Schwendeman
Delegated Party Title:
Regional Environmental Manager
Permit Number:
NCS000582
Email Address:
[e-mail]
I Phone:
216-210-9827
Mailing Address:
6088 Summer Lake Dr
City:
Medina
State:
CH
I Zip:
44256
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:
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, Randy Krahn (printed name),
have the authority to enter into this Agreement for
Ennis Flint
(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, Randy Krahn (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Responsible Official Signature
Plant
Title
zy �-
bate
Stormwater Permit Delegation of Signatory Authority Form
Page 3