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HomeMy WebLinkAboutNCS000476_SW Permit DOSA_20220812NC Department of Environmental Quality 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 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/wham 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 far 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. o For a partnership or sole proprietorship, the Responsible Official shall be a general partner or the proprietor, respectively, or e 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: ail b n Responsible Official Name: NA 5ch.eu.er Responsible Official Title: t�Fnano-qer Email Address: ;1Sc et r C n Phone: BIB, 64B,23(o Mailing Address: City: �' Qn+b State: N L Zip: AB-11(p 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: 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: 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, N Ic � ch i Aer (printed name), have the authority to enter into this Agreement for i [5r�n c)f O'ar>TOn (Owner/Organization Name). request that the DEMLR Stormwater Program include the persons listed in Part A of this form signatory authority for the above -named permit. 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, 1, N IC (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 Title aVKKZ./- G 1la v a Date Stormwater Permit Delegation of Signatory Authority Form Page 3