NCS000390_DOSA Form_20220927

I ku RECEIVED
QWLR-Stormwater Program
NC Department of Environmental Quality
•'�' Division of Energy, Mineral and Land Resources
mn.•n.,..eaQuaulr
Stormwater Permit Delegation of Signature Authority Form
0,rertlons are in red
This form shall be used to delegate signature authority from the permit Owner (Permittee) to
anotherparty. 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 relleve the Permit Owner from the responsibility for permit
compliance.
a The permit Owner is the legal entity to whichfwhom a permit has been issued, and maybe 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 inalit) CFR 127.72. summarized
below,
• Fora corporation, the Responsible Official shall be a president, secretary. treasurer, orvice.
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, fire 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 ofcer!City/County Manager) or 2M;ing elected official fMayorl.
a Even it delegated signatory authority has been delegated to another individual. the Responsible Official
retains responsibility for compliance with permit conditions.
Organization Name: Heritage Crystal Clean, LLC
Responsible Official Neme: Anita Decina
Responsible Official Title: Vice President. Operational, Safety 8 Environmental Excellence
Email Address: [e-mail] IPhone:1847-783-5924
Mailing Address: 2000 Center Drive, Suite East C300
City: :Hoffman Estates State: 41- Zip: 60192
Stormwater Delegation of Signature Authority Form
Page 1

M.:
A. Persons to Receive Signatory Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name: lRebekah Schulenberg
Delegated Party Title: Environmental Manager
Permit Number: _ NC5000390
Email Address: Phone:
MilThg Address: 000 Center Drive. Suite East C300
City:Hoif EstataIWV� I State: IIL _ ZiP: 60192
i Slgne�ure of Delegated Party Indicating
ameplenee of Signatory AuNodty: —._.
Date:
Delegated Party Name: Greg Taylor
_D_elegated Party Title: Plant Manger
Permit Number. _ NCS000390
Email Address: [e-mail] I Phone: I(704) 634-0006
Mailing Address: 2115 Speedrail Ct.
City: Concord I State: NC I ZIP: 128025
Signature or Delegated Pany Indicating
acceptance of Signatory AuNodty.CJ_
Delegated Party Name:
Delegated Party Title:
Permit Number:_
Email Address:
I Phone:
Mailing Address:
City: _.— --
--- — ---- State: ZIP. ( --
Signature of Delegated Party indical'ng
acceptance of Signatory Authority.
Date:
Delegated Perry Name: I
Dele ated Party Title_:
Perot Number:
Email Address: I Phone:
Mailing Address:
City:'
, Signature of Delegated Party indkaling
accepumce of Signatory Authority
Date: - ----- ----- —
Slormwater 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. Anita Decina _ (printed name).
have the authority to enter into this Agreement for
Heritage Crystal Clean, LLC (OwnedOrganization 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.
acknowledge that I, and the persons listed in Part A of this form work atlfor my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, Anita Decina (printed name),
have read, understand, and accept the terms and conditions of the stonnwaler permit(s) for
which I am the Responsible Official.
UK-, 1>w�
Responsible Official Signature
Vice President, Operational, Safety & Environmental Excellence
Title Date
Stonnwater Permit Delegation of Signatory Authority Form
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