NCS000134_SW Permit DOSA_20230313

ROY COOPER
Governor
ELIZABETH S. BISER
Secretory
DOUGLAS R. ANSEL
Interim Director
NORTH CAROLINA
Envrrntimenrar Quality
Stormwater Delegation of Signature Authority Form (DDSA)
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 he 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 he either a
principal executive officer [City/County Manager] or ranking elected official [Mayor].
Please mail the DOSA Form with original wet signatures to: NCDEMLR Stormwater
Program, 1612 MSC, Raleigh, NC 2 7699 -1612
Name of Organizational Entity
AN Occ, LLC.
Responsible Official Name
Responsible Official Title:
Email Address:
Ci UUS , ser ' St.,^a "\'W
Phone 12SI-lib2
-213 3
MailingAddress
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City
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State
Zip code
219 !S-7
North Carolina Department of Envlronmental Quality I Division of Energy. Mineral and Land Resources
W North Salisbury Street 1 1612 Mail Set vice Center I Raleigh, North Carolina 27699-1612
919.707.9200

A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Attach additional pages if you need more space.
Delegated Party Name
Yr F M . cov%e-v'
Delegated Party Title
E µs nw." ee
Permit Number(s)
pi G S 0 0 0 I ,3 4
Email Address:
6V'%a^ • COnVItv-@ a&
Phone
I
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MailingAddress
PO SCx aq
City
t
State
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Zip code
2-jg5-7
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
�ti•
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address:
Phone
MailingAddress
city
State
Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Party Title
Permit Numbers)
Email Address:
Phone
MailingAddress
City
State
zip code
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 CER 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
I
As the Responsible Official,1, �'-' v�'� %Y\V s �l�+�v►� SQn (printed name),
have the authority to enter into this Agreement for
Ncco, LLL (Owner/Organization Name),
1 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, Aj� vS' -,^AAc Qre%*Sqyy (printed name), have read,
understand, and accept the terms and conditions of the stormwater permit(s) for which 1
am the Responsible Official.
aA; V/� � �
Responsible rc' Signature
��s;dlc�nk 3 - 13 - 2. oz 3
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

Avoca, LLC
PO Box 129
V 1341 Avoca Farm Rd
p Merry Hill;, NC 27957
Phone: [phone]
The World's Premier Botanical Extraction Company Fax: [phone]
February 21, 2020
RE: Delegation of Signatory Authority for Environmental, Health, & Safety Reports and Documents
To Whom it may Concern:
As President of Avoca LLC, I duly authorize the EH5 Manager of Avoca LLC to sign, certify, and submit all
reports, applications, notifications, and other documents associated with the below referenced permits
and reports for the 3 Avoca sites located at Merry Hill, NC, Summerville, SC, and Menomonee Falls, WI:
Air Quality — Annual Compliance Certifications, SARA 313 R Annual Reports, Annual Emissions inventory
Reports, Semi -Annual Reports, Semi -Annual MON Reports, Semi -Annual Boiler Reports, Periodic
Equipment CEDRI Reports
BATF--Annual Alcohol User Report
EPA --Annual Pesticide Producer Report
Wastewater Treatment-- Monthly Reports, Quarterly Groundwater Monitoring Reports, Annual Lab
Certification
5tormwater—Monthly Reports, Quarterly Reports
Hazardous Waste-- Biennial Hazardous Waste Report
Tier 11- Annual Report
OSHA —Annual 300 Log
Our current EHS Manager is Brian Conner, who can be contacted with any questions at [phone].
Sincerely,
Augustinus Gerritsen
President
Avoca LLC