NCG050397_SW Permit DOSA_20230327

ROY COOPER
Gmernor
ELIZABETH S. BISER
Secrerury
DbUGLAS R. ANSEL
lnfetIm Director
NORTH CAROLINA
Environmental Quality
Stormwater Delegation of Signature Authority Form (DOSA)
This Form shall be used to delegate signature authority From the permit Owner (Permittee) 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 OEMLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit owner from the responsibility and 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:
Fora corporation, the Responsible Official shall bea president, secretary, treasurer, orvice 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.
Fora partnership or sole proprietorship, the Responsible Official shall be 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 ran ki ng elected official [Mayor].
Please mail the DO SA Form with ❑riginaI wet signatures to: NCDEMLRStormwater
Program, 1612 MSC, Raleigh, NC 27699-1612
Name of Organizational Entity
r�c�iv LLB .
Responsible Official Name
Responsible Officia] Title:
Email Address:
�+ny � ft R f I L ��l ;��hone
• •
j6jq-qq0-0230
MailingAddress
Mud,
City
Kinshirw
State
I K.C. I Zip code
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North Carolina Acpartment of Environmental Quality I Division of Energy, >4lirseral and Land Resources
e�-"DEQ 512 North Sallsbury St re el 11612 MalI Service Center I Raleigh, North Carolina 276,99-1612
o--•�=- o-ra 919.707.9200

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
Delegated Party Title
Permit Number(s)
Email Address:
Phone
Mailing Address
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
Mailing Address
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 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,1, j6G y1_ ��f�4+ti7 (printed name),
have the authority to enter into this Agreement for
8"m L L C - (Owner/Organization Name).
1 request that the ❑EMLR Stormwater Program include the persons listed in Part A of this
form signatoryauthority far 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 far purposes of the NCDEQ's
electronic document systems.
By submitting this application,1, I�kn I RAMts— (printed name), have read,
understand, and accept the terms and conditions of the stormwaterpermit(s) for which I
am the Responsible Official.
'��Am P-'L S
Res a ible 0 ici I Signature
V� 5 16? 7 Do-) -3
Title Date
Stormwater Permit ❑elegation of Si gnato ry A u thori ty Form
Page 3