NCG060335_SW Permit DOSA_20231102

ROY COOPER ll ,
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Governor ',e } I r.•' •.
ELIZABETH S.BISER
� '
Secretary
DOUGLAS R.ANSEL NORTH CAROLINA
interim Director Environmental Quality
Stormwater Delegation of Signature Authority Form (DOSA)
This form shall he 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
,• • e• 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 he 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 he 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 he a general partner or the
proprietor,respectively;or
• For a municipality,State,Federal,or other public agency,the Responsible Official shall he either a
principal executive officer[City/County Manager]or ranking elected official[Mayor].
Please mail the DOSA Forst with original wet signatures to: NCDEMLR Stormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity ^,�,�L ,,iv____* (No/r/t1(� I r�io
Responsible Official Name 4 / -
Responsible Official Title: ems`
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Email Address: Phone\i'41 ,0fes6Srtril. Devi 0--S5/ 7
Mailing Address Po 7
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City n /_ _ State ^t Zip code fug4
North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
DE 512 North Salisbury Street 11612 Mail Service Center I Raleigh,North Carolina 27699-1612
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 �•M -ftRi
Delegated Party Title J,ryo 11 fly ��� P7i�// �arvat,9 sty_ra l7on►�i
Permit Number(s) nJ CC, o 6 a 3 3s
Email Address: Carr. preg 5. fii Phone eplo
Mailing Address '�p,3°K Y,3$
City � State iye Zip code Q 3R
Signature of Delegated Partyc40.#:4
((
indicating acceptance of
Signatory Authority:
Date /D- 3/ - 2.3
Delegated Party Name An �,� apt 7`
Delegated Party Title Ain/time/pc/ ,t f , //
Permit Number(s) Ai V / U
Email Address: el_hey4,111-
/G� // f ne 4/0Pho4/0.59)353
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Mailing Address /tV AD X 3
City St Zip code y(3).G)
G ate C /
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date /).J/. �J
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
Stormwaterl'ermit 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 subm' reports for the organization.
As the Responsible Official,I, J h �'�_ (printed name),
have t authority to enter into this Agreement fort/
_ (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.
l 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,1, Jn h` r (printed name),have read,
understand,and accept the terms and conditions of the stormwater permits)for which
am the Responsible Official.
Res nsible Official Sign ure
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3