NCG060028_Stormwater Delegation of Signature Authority Form DOSA

ROY COOPER
ca,r oar
ELIZABETH S.BISER _
SenMary
DOUGLAS R.ANSEL NORTH CAROLINA
mrenm rnrcnw EnNronmenml Qugftry
Stormwater Delegation of Signature Authority Form (DOSA)
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 nd compliance for
permit compliance,
Permit Owner: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 orthe
proprietor,respectively;or
• For a municipality,State,Federal,or other public agency,the Responsible Official shall be either
principal executive officer[City/County Manager]or ranking elected official[Mayor].
Please mail the DOSA Form with original wet signatures to: NCDEMLR Stormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity AbM I v
Responsible Official Name
0
Responsible Official Title:
er �o S G a er
Email Address: Phone
oJ. a.44e-r.. JQ,M.cr t, 704-33.2"3/4"5
Mailing Address
o LJ . /o tA S-l-e,ee
City State Zip code
r/. O
North Carolina Department of Environmental Quality l DMsionaf Enemy.kfineral and Land Resaurms
512North S.Ihb.ry Slreet 11612kfallS mrN CenterIR leigh.Narth Carolina22699-1612
919.70T.9200

A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Attach additional pages if you need more space.
Delegated Party Name C
Delegated Party Title /
c c r
Permit Numbers) CG OO
Email Address: Crci Phone ,33 _ f6
MailingAddress (G O 0Y� Sfree�
City r Jd State NC_ I Zip code O
Signature of Delegated Party
indicating acceptance of ' /
Signatory Authority: /
Date
` O
Delegated Party Name
Delegated Party Title
Permit Numbers)
Email Address: Phone
MailingAddress
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address: Phone
MailingAddress
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Stormwater Permit Delegation of SignatoryAuthority Form
Page 2

B. Responsible Official Signature
The Responsible Official, as identifiedin accordancewith40 CFR 122.22, is the appropriate
individual with the authorityto sign and submitreports for the organization.
As the Responsible Official,I, Qr_; c ��oc��e� (printed name),
have the authorityto enter into this Agreementfor
(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 that1,and the persons listed in PartA of this form work at/formy
organization and have authorityto act as a signatory for purposes of the NCDEQ's
electronic document systems. n
By submitting this application,I, Go, ry (printed name),have read,
understand,and accept the terms and h nditionsofth stormwaterpermit(s)forwhichI
am the Responsible Official.
Respo//// /V eOf,{ficciialSi t e I �7
L /T , o,g9er
Title Ij Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3