NCG140030_SW Permit DOSA (2)_20220629

NC Department of Environmental Qualify
NORTH CAPO-UN.,4 Division of Energy, Mineral and Land Resources
EnrirDlYlri1And 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 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 4g 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:
Responsible Official Name:
Responsible Official Title:
Email Address:
Mailing Address:
City:
Loflin Concrete
Chad Loflin
President
[e-mail]
2105 Pisgah Church Rd
Kernersville
Phone: [phone]
Skate: I NC i zip. 127284
Stormwater Delegation of Signature Authority Form
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