NCG030729_SW Permit DOSA_20220913

°1 # 'y.f4 NC Department of Environmental Quality
\` °'"' Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental Qaolu,
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 Storm water 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.
Permittee: PowerSecure Manufacturing, Inc.
Permit Number. NCG030729
Responsible Official Title: Director of Manufacturing
Email Address: [e-mail] Phone: j(91 9) 761-0277
Mailing Address: 4068 Stirrup Creek Dr.
City: Durham State: NC riP= 27703
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: Scotty Moates
Delegated Party Title: Environmental Permitting and Compliance Manager
Delegated Party Organization: PowerSecure Manufacturing, Inc.
Email Address: [e-mail] Phone: [phone]
Mailing Address: 4068 Stirrup Creek Dr.
City: Duff m State: NC Zip: 27703
Signature of Delegated Party indicating
acceptance of Signatory Authority: ��/ppp
Date_
Delegated Party Name: Adam Daniel
Delegated Party Title: Facilities and Tanks Environmental Compliance Manager
Delegated Party Organization: PowerSecure Manufacturing, Inc.
Email Address: [e-mail] I Phone: I(919)632-2913
Mailing Address: 4068 Stirrup Creek Dr.
City: Durham State: NC Zip: 27703
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date: — 7 /ADZ
Delegated Party Name: Scott Unthacum
Delegated Party Title: Facilties Environmental Compliance Specialist
Delegated Party Organization: PowerSecure Manufacturing, Inc.
Email Address: [e-mail] Phone: [phone]
Mailing Address: 4068 Stirrup Creek Dr.
City: Durham Tate: INC Zip: t27703
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date: - S/311 20�Z
Delegated Party Name: -
Delegated Party Title:
Delegated Party Organization:Email Address: Phone:
Mailing Address:
City: State: Zip: I
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of Signatory Authority Form
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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, Jason Mitchell (printed name),
'lave the authority to enter into this Agreement for
PowerSecure Manufacturing, Inc. (Owner/Organization Name).
I request that the DEMLR Stormwater Program include the persons listed in Part A of this fora-
signatory authority for the above-named permit.
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, Jason Mitchell (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Res nsible Official Signature
Director of Manufacturing 8/.3//o2(");
Title Date
Stormwater Permit Delegation of Signatory Authority Form
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