NCG120066_Delegation of Signature Authority_20210621

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4D NC Department of Environmental Quality
NORTH C..RpLINA
Division of Energy, Mineral and Land Resources
Environmental Quariry
Stormwater Permit Delegation of Signature Authority Form
Directions are in red. Fl
This form shall be used to delegate signature authority from the permit Owner (Permittee)'UN 212021
another party. Only the Responsible Official defined below may submit permit applicatigg�
reports required by the permit (such as Data Monitoring Reports and Annual ReportsivD QUALITY
form is completed and submitted to the DEMLR Stormwater Program. Please note that delegaf nc�FtRfI�ITTING
signature authority does not relieve the Permit Owner from the responsibility for permit
compliance.
The permit Owner is the legal entity to whichAvhom 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.
Po' ;++
I vvllKes County
Permit Number:
NCG120066
Responsible Official Title:
John Yates
Email Address:
Mailing Address:
[e-mail] Phone: [phone]
County Office Building 110 North St
City:
Wilkesboro
State:
NC �ZiP:�28669
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:
Anderia Byrd
Delegated Party Title:
Director
Delegated Party Organization:
Wilkes County Department of Solid Waste
Email Address:
abyrd@wilkescounty_net
I Phone:
336-696-5806
Mailing Address:
PO Box 389
City:
Roaring River
State:
I NC
I Zip:
28669
Signature of Delegated Party indicating
acceptance of Signatory Authority:]
i Date:
6-10-21
Delegated Party Name:
Linda Souther
Delegated Party Title:
Recycling Coordinator
Delegated Party Organization:
Wilkes County Department of Solid Waste
Email Address:
([e-mail]
I Phone:
336-696-3867 ext 941
Mailing Address:
PO Box 389
City:
Roaring River
State:
NC
Zip:
28669
Signature of Delegated Party indicating
acceptance of Signatory Authority:
yn _ _
r CT�%��i[X��.
Date:
6-10-21
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
City..
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
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, 1,
have the authority to enter into this Agreement for
Wilkes County (Owner/Organization Name).
(printed 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, Tc h n Y C., j t s (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
4 *,�i
Responsible Official Signature
County Manager
Title
6-10-21
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3