NCS000508_SW Permit DOSA_20230717

111 Corning Road
Suite 200
Cary,NC 27518
United States
7 T+1.919.859.5000
Saco bs F+1.919.859.5151
wwwjacobs.com
NCDEMLR Stormwater Program Fully executed wet signature
1612 MSC copy of DOSA has been
Raleigh, NC forwarded by Piedmont Triad
27699-1612 Airport Authority.
June 27, 2023
Subject: Stormwater Delegation of Signature Authority Form(DOSA)
Permit No.NCS000508
To whom it may concern,
Attached is a Stormwater Delegation of Signature Authority Form(DOSA)which includes revisions to
current signature authorization for Permit No.NCS000508. Please ensure this is revised in the
system to prevent delays in Data Monitoring and enable the future transition to eDMR system.
If you have any questions or need further information,do not hesitate to contact myself or Richard
Darling at our office.
Sincerely,
.-14- 9..X.(1\A-ArYD
Jennifer Da m
Project Controls

• . . d_ W
ROY COOPER ,
Governor
•
ELIZABETH S.BISER `� - a^ 'Aft
Secretary .4`?i"jY0`*-
DOUGLAS R.ANSEL NORTH CAROLINA
Interim Director 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 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 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:
• 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].
Please mail the DOSA Form with original wet signatures to: NCDEMLR Stormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity Piedmont Triad Airport Authority
Responsible Official Name
Kevin J Baker
Responsible Official Title: Executive Director
Email Address: [e-mail] Phone [phone]
Mailing Address 1000a Ted Johnson Pkwy
City Greensboro State NC Zip code 27409
A North Carolina Deportment of Environmental Quality i Division of Energy.Alineral and Land Resources
^ ,1JNorthSalisburyStreet 1612MeiIServiceCcnlrr Raleigh.North Carolina2769n 1612
wwvnm c,Lnrew Dud � 9)9707.4200

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 Stephen Rich
Delegated Party Title Project Manager
Permit Number(s) NCS000508
Email Address: [e-mail] Phone [phone]
Mailing Address 1000a Ted Johnson Pkwy
City Greensboro State NC Zip code 27409
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name J. Alex Rosser
Delegated Party Title Chief Operating Officer
Permit Number(s) NCS000508
Email Address: [e-mail] Phone [phone]
Mailing Address 1000a Ted Johnson Pkwy
City Greensboro State NC Zip code 27409
Signature of Delegated Party i
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name Richard Darling
Delegated Party Title Senior Environmental Scientist
Permit Number(s) NCS000508
Email Address: [e-mail] Phone [phone]
Mailing Address 14120'Ballantyne Corporate Place, Suite 200
City Charlotte State NC Zip code 28277
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 2

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 Jennifer Damm
Delegated Party Title Project Controls
Permit Number(s) NCS000508
Email Address: [e-mail] Phone
Mailing Address 111 Corning Road, Suite 200
City Cary State NC Zip code 27518
Signature of Delegated Party indicating acceptance of
Signatory Authority: 70-,ti
C1
Date 51191 3.3
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
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 Baker _ (printed name),
have the authority to enter into this Agreement for
Piedmont Triad Airport Authority (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 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 Baker (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 Signature
Executive Director
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3