NCG190106_DOSA Form_20220630

RECEIVED
NC Department of Environmental Quality
oEMLR Stormwater Program
'' Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental Qaarfly
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 40 CPR 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:
U.S.A.C.E. Engineer Repar Yard
Responsible Official Name:
Daniel Brown
Responsible Official Title:
Chief of Operations Division
Email Address:
[e-mail]
I Phone:
910-251-4832
Mailing Address:
232 Battleship RD
City:
Wilmington
State: -
NC
ZIP:_
28401
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:
Anthony watts
Delegated Party Title:
Marine Machinery Mechanic
Permit Number:
NCG190106
Email Address _
[e-mail]
Phone:
g10-2a1-6soa
Mailing Address:
City:
232 Battleship Rd
Wilmington
State
NC
Zip1. j
284g1
_
Signature of Delegated Party indicating
acceptanceof Signatory Au_thorit_y_:
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Phone:
Mailing Address:
—
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Permits Number.
Email Address:
Phone:
Mailing Address:
State: Zip:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number:
_
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

•
r
A. Persons to Receive Signatory Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated
Delegated Party Title` ----!
Permit NUmtier•
Ernat! Address: Phone:.. -
Mailing Address
City State: Zip
Signature of ©etegated'Party indicating
acceptance of signatory Authdiit)r _
Date:
Delegated Party Names _
Delegated Party Title:-:
Permit -.Number :..:. -----
Ernait Address: Phone:: r
Matlirig'Address . _ .: ____�
City
Slgnaturs..p t7eiegatedParty :indicating
ecco fAncc of:Signatory_Aistwhc6i
Delegated Party.'. Name, `..
,_,_.
Delegated Party Tile:
Per A: Number
Email Address
W Phone`
_
_
City .
State:: Zip:
Signaturo of tYelegated Party irtdicating::,
�'acceptance: ofSignatofyAt�thotity:...` : •�-
Date
Storrnwater 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, I,
Daniel Brown
have the authority to enter into this Agreement for
USACE Engineer Repair Yard (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, Daniel Brown (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
MR M-MUNA191110
Responsible Official -
Chief of Operations Division 6 jpA C) a 2
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3