NCG110081_SW Permit DOSA_20230125

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH GAROLINA
Fnvirau�en)o1 Q-W
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 122.22. 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: (Wilson WWTP
Responsible Official Name: IGrant Goi
Responsible Official Title:
Email Address:
Mailing Address:
L City:
City Manager
[e-mail] Ph52-399-2200
PO Box 10
Wilson State: NC Zip: 27894
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:
Bill Bass
Delegated Party Title:
Director of Public Works
Permit Number:
NCG110081
Email Address:
[e-mail]
Phone: [phone]
Mailing Address:
City:
PO Box 10
WIIS99
tate:
INC Zip:
27894
Signature of Delegated Party indicating
acceptance of Signatory Authority:
r
Date:
f
Delegated Party Name:
Kyle Manning
Delegated Party Title:
Assistant Director of Public Works
Permit Number:
NCG110081
Email Address:
[e-mail]
I Phone:
252-296-3416
Mailing Address:
PO Box 10
Wilson State: NC Zip: 27894
r —�
�-
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
-Pate:
Delegated Party Name:
Samuel Hedgepeth
Delegated Party Title:
Assistant Director of Public Works
Permit Number:
NCG110081
Email Address:
[e-mail]
Phone: [phone]
Mailing Address:
PO Box 10
City:
Wilson State:
NC
Zip:
27894
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
...: 5 a,23
Delegated Party Name: Jimmy Pridgen
Delegated Party Title: Water Reclamation Manager
Permit Number: NCG110081
Email Address: pridgen tlBe r one: 252-399-2491
Mailing Address:
City: Wilson te: NC Zip: 27894
Signature of Delegated Partly ndicati
acceptance of Signatory A thority:
Date: _ y
5tor tV,rper*nffI1 elegation of Signatory Authority Form
Page 2

A. Persons to Receive Signatory Authority
=> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Noah Parsons
Delegated Party Title:
Water Infrastructure Manager
Permit Number:
NCG110081
Email Address:
[e-mail]
I Phone: [phone]
Mailing Address:
PO Box 10
WiIS9674 I State: JNC I Zip 27894
_
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
0IM123
Delegated Party Name:
Tiffanie Garner
Delegated Party Title:
Stormwater Com
Permit Number:
NCG110081
Email Address:
tgarner@wilsonn
Mailing Address:
PO Box 10
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Wilm
Date: l V1 LI 0 1 U 2.3
ce Specialist
Phone: [phone],
State: INC Zip:
Delegated Party Name:
Nicholas Eatmon
Delegated Party Title:
Operations and Maintenance Supervisor
Permit Number:
NCG110081
Email Address:
[e-mail] I
Phone: [phone]
Mailing Address:
PO Box 10
_
City:
Wilson I State:
INC
I Zip
27894
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
/- y- O ?,r
Delegated Party Name:
Delegated Party Title:
Permit Number: _
Email Address:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
aura Pruitt
later Reclamation
CG110081
[e-mail],
OBox 10
Filson
2kxlla'nLd gy
q- 2o73
Coordinator
Phone: [phone]
State: INC I Zip: 11
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, Grant Goings (printed name),
have the authority to enter into this Agreement for
The City of Wilson WWTP (Owner/Organization Name).
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, Grant Goings (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 Si
City Manager
Title
D to
Stormwater Permit Delegation of Signatory Authority Form
Page 3