NCG200516_DOSA Form_20221027

RECEIVED
OG � 17 ZW
>? 'q DEMLR-Stormwater Program NO Department or Environmental Quality
Division of Energy, Mineral and Land Resources
%URN, CA,I"ONA
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Stormwater Permit Delegation of Signature Authority Form
Dauctions oiu ei red.
This form shall be used to delegate signature authority from the permit Owner tPornuttee) to
another parry. 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 DEMUR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility forpermit
compliance.
Thu permit Owner is the legal entity to whrdVwhom a permit has been issued, and maybe an individual
Oran organization such as a company or government agency EveryOwner is roquved to have a
Responsible Official who meets the legal signature authority requirements in QQ 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 lMayorl.
Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
Organization Name:
IMET Alloys
Responsible Official Name:
Mike Oruska
Responsible Official Title:
coo
Email Address:
[e-mail]
I Ph"--
704225-9932
Mailing Address:
3000 Stitt Street, Suite 150
City: IMonroe
State:
NC
ZIP:
28110
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
The signatures of the persons listed below indlcales their acceptance of signatory authority.
Del ated Party Name:
David Moore
Delegated Party Title:
Director of Continuous Improvement
Permit Number.
NCG200516
Email Address:
[e-mail] I Phone:
704-441.2573
Mailing Address:
3000 Stitt street, Suite 150
City:
Monroe
I State:
INC
I ZIP:
128110
Signature of Delegated Party indicating
acceptance of Signa!M Authonty.
Date:
- 7 - Z.
Delegated Party Name:
Delegated Party Title:
Permit Number.
Phone:
Email Address:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority.
Date:
Delegated Parry Name:
Delegated Party Title:
Permit Number.
Phone:
Email Address:
Mailing Address:
City:
State:
Zlp:
Signature of Delegated Parry Indicating
acceptance of Signatory Aufhorily.
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number.
Email Address:
Phone:
Meiling Address:
j
City:
State:
Zlp:
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, Mike Oruska
have the authority to enter into this Agreement for
IMET Alloys (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 1, 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. Mike Oruska (printed name),
have read, understand, and accept the arms and conditions of the stormwater permit(s) for
which 1 am the Res ible Offici
Responsi a Official Signa
Title
/V /3;Ze,>
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3