NCG210136_DOSA Form_20220815

RECEIVED
y yTAif .
Zii ?7 NC Department of Environmental Quality
. DEMLR StormV,l'' ^'
Ijit�i on of Energy, Mineral and Land Resources
NORTH CAROLINA
Eadroaa WlQualtry
Stormwater Permit Delegation of Signature Authority Form
40 CFR 122.22
Organization Name:
Columbia Forest Plywood Products
Responsible Official Name:
Randy Marsh
Responsible Ofo,�iel Title-
Plant Man?3er
Email Address:
[e-mail]
I Phone:
828_724-4191
Mailing Address:
369 Columbia Carolina Road
City:
Old Fort
State:
NC
zip
28762
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
Delegated Party Name:
Nason Banner
Delegated Party Title:
Permit Number:
NCG210000 t',J C b Z t G l
Email Address:
[e-mail]
I Phone:
818-724-4191
Mailing Address:
369 Columbia Carolina Road
City:
Old Fort
I State:
NC
Zip:
28762
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:
Data:
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:
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

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, Randy Marsh (printed name),
have the authority to enter into this Agreement for
Columbia Forest Plywood Products (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, Randy Marsh (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
Plant Manager O Z Z_
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3