NCS000508_SW Permit DOSA_20221216

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CAROLINA
fnvtr®nmsntal 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 40 CFR 122.22summarized
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:
Piedmont Triad Airport Authority
Responsible Official Name:
Kevin J. Baker
Responsible Official Title:
Executive Director
Email Address:
[e-mail]
I Phone:
[phone]
Mailing Address:
1000A Ted Johnson Parkway
City:
Greensboro
I State:
�NC
I zip: 127409
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
Tr►e slgnwupres of the pop sons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
J. Alex Rosser, P.E.
Delegated Party Title:
Chief Operating Officer / (Owner Contact Person)
Permit Number:
NCS000508
Email Address:
[e-mail]
I Phone: [phone]
Mailing Address:
Piedmont Triad Airport Authority; 1000A Ted Johnson Parkway
City:
Gree sboro
I State:
NC
I Zip: 27409
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
2 1 2
Jon
Delegated Party Name:
Stephen Rich, P.E.
Delegated Party Title:
Project Manager / (Facility, Permit, Billing Contact Person)
Permit Number:
NCS000508
Email Address:
[e-mail] Phone:
[phone]
Mailing Address:
Piedmont Triad Airport Authority; 1000A Ted Johnson Parkway
City:
Green boro State:
NC
Zip
27409
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Ii ? U
Delegated Party Name:
Richard Darling
Delegated Party Title:
Project Manager - Environmental / (Electronic Signature Authority)
Permit Number:
NCS000508
Email Address:
[e-mail]
Phone:
[phone]
Mailing Address:
Michael Baker International; 200 Centreport Drive Suite 350
City:
Gre sboro
I State:
NC
I Zip:
27409
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
12/16/2022 or
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Phone:
Mailing Address:
City:
State:
T 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, Kevin J. Baker
have the authority to enter into this Agreement for
Piedmont Triad Airport Authority (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, Kevin J. Baker (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Executive Director
Title
Signature
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3