Loading...
HomeMy WebLinkAboutNCG080878_DOSA Form_20220812RECEIVED .W I CZa NC Department of Environmental Quality •�.:�� DEMLR-Stormwater Proion of Energy, Mineral and Land Resources NORTH CAROLINA En•ir a ralQaallry Stormwater Permit Delegation of Signature Authority Form Directions are in red. :7> This form shall be used to delegate signature authority from the permit Owner (Pemtittee) 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: Waste Industries LLC Responsible Official Name: Joseph Santangelo Responsible Official Title: Regional Environmental Compliance Manager Email Address: joseph@santangelo@gflenv.com Phone: (724) 244-9511 Mailing Address: 3301 Benson Drive Suite 601 City: Raleigh I State: NC I ZkV. 27609 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: James D. Frei Delegated Party Title: Consultant Permit Number: NCGO80878 Email Address: jdfrei@stormwatergroup.com I Phone: 919-661-9954 Mailing Address: 8916 Oregon Inlet Ct City: aleig I State: NC I Zip: 127603 Signature of Delegated Party indicating acceptance of Signatory Authority: n E/ Date: 07/0712022 Delegated Party Name: William smith Delegated Party Title: operations Supervisor Permit Number: NCG080878 Email Address: william.smith@gflenv.com Phone: I 910-2534177 Mailing Address: 2809 Galloway Rd NE City: Bolivia I State: NC ZIP: 28422 Signature of Delegated Party indicating acceptance of Signatory Authority: Al A M Date: 07/07/2022 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, Joseph Santagelo (printed name), have the authority to enter into this Agreement for Waste Industries 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 attfor my organization and have authority to act as a signatory for purposes of the NCDEQ's electronic document systems. By submitting this application, I, Joseph Santangelo (printed name), have read, understand, and accept the terms and conditions of the stormwater permit(s) for which I am the Responsible Official. fe le Official Signature Regional Environmental Compliance Manager 07/07/2022 Title Date Stormwater Permit Delegation of Signatory Authority Form Page 3