NCG120068_Delegated Signature Authority_20210614

McCoy, Suzanne
From: Grzymski, Amber <[e-mail]>
Sent: Monday, June 14, 2021 10:37 AM
To: McCoy, Suzanne
Cc: Smithberger, Jeffrey; Hack, Joe; Steinhilber, Darren J.
Subject: [External] Mecklenburg County Solid Waste Designation of Authority Form
Attachments: Stormwater Delegation of Authority Form 6-21.pdf
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Ms. McCoy,
Please see the attached designation of authority form for the Mecklenburg County Solid Waste NPDES permits. The
original is in the mail. Please let me know if you have any questions or need any additional information.
Thanks,
Amber
Amber R. Grzymski, P.G.
Mecklenburg County Land Use and Environmental Services
Solid Waste Engineering
2145 Suttle Ave
Charlotte NC 28208-5237
980-314-3855
Mobile: [phone]
1

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORiH CAROLINA
pnvtronmentat 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/whom 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 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.
Permittee:
Mecklenburg County Solid Waste
Permit Number:
NCG120068, NCG240016, NCG240019
Responsible Official Title:
Jeffrey Smithberger
Email Address:
[e-mail]
Phone:
980-314-3863
Mailing Address:
2145 Suttle Ave
City:
Charlotte
State:
NC
I Zip:
28208
Stormwater Delegation of Signature Authority Form
Page 1

B. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 122.22, Co the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, I, Jeffrey Smithberger (printed name),
have the authority to enter into this Agreement for
Mecklenburg County Solid Waste
(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, Jeffrey Smithberger (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
Solid Waste Director
Title
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

A. Persons to Receive Signatory Authority
=> The signatures of the persons Listed below indicates their acceptance of signatoryauthority.
Delegated Party Name:
Joe Hack
Delegated Party Title:
Senior Project Manager
Delegated Party Organization:
Mecklenburg County solid Waste
Email Address:
[e-mail]
I Phone:
980-314-3864
Mailing Address:
2145 Suttle Ave
City:
Charlotte
I State:
NC
I Zip:
28208
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Amber Grzymski
Delegated Party Title:
Project Manager
Delegated Party Organization:
Mecklenburg County solid Waste
Email Address:
[e-mail]
Phone:
980-314-3855
Mailing Address:
2145 Suttle Ave
City:
Charlott
State:
NC
I Zip:
28208
Signature of Delegated Party indicating
acceptance of Signatory Authority:
f
Date:
Delegated Party Name:
Darren steinhilber
Delegated Party Title:
Project Manager
Delegated Party Organization:
Mecklenburg County solid Waste
Email Address:
[e-mail]
Phone:
980.314.3857
Mailing Address:
2145 Suttle Ave
City:
Charlotte
I State:
NC
I Zip:
28208
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
411e elli
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
City:
IState:
IZip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of Signatory Authority Form
Page 2