NCS000211_SW Permit DOSA_20231222

ROY COOPER
Governor ",
ELIZABETH S.BISER
Secretary
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 D
lrl4-esTlA Ot1A1 T0.ibe-r.. Cemw.rPC!N•st
Responsible Official Name
Responsible Official Title:
v4 — Mo.e•iaXo .r4nq — P..-1P
Email Address: Phone
1ftw.}GR V�.\�t.\4�GM1 rapes. 9e\- 1414%- -.4.494.
Mailing Address
6Noo ?oQ\vl- Rye
City IH�pk.b State 1-VA Zip code S41
q1'
D_E Q North Carolina Department of Environmmta Quality I bivisinn or Energy,
Mineral and Land Resources
512 North Salisbury Street 11612 Mail Service Center Raleigh.North Carolina 27699-1612
+r+sheen0r 11•ONs Jr*" 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 J s t-'\t1-re.�.
Delegated Party Title r.�.;cvnr.e.r04-a.\ AO-r• e.e
Permit Number(s) rat GS o 0 0 211
Email Address: 3NgAke%, rnG-te-re;Pa.Q�c o,or•• Phone [phone]-Zo6
Mailing Address is
Cif, �Ja c.e.\cot-o State +�L Zip code Z.415%6
Signature of Delegated Party
indicating,acceptance of
Signatory Authority:
Date 12.12\ VS
Delegated Party Name Ca;�1-1r, Sp+a�1n�
Delegated.Party Title Er\v�v•onr.ul-ca•\ En51ne-er
Permit Number(s) N C.S o 00 211
Email Address: CacAkyn. 4,41Grb; ee ,paloe-Cs COS.. Phone as 2,- 400
Mailing Address il.$15 Ve-leek...we4-Aser Rd
City State HL Zip code Z�S86
Signature of Delegated Party . _
indicating acceptance of
Signatory Authority:
Date 1 212112 3
Delegated Party Name To--1 oc-
Delegated'Party Title g\a.s t \ar>ex st r'
Permit Number(s) WS o0o Z\\
Email Address: ;�,7***ek rl , ,-a-=\oCfAiPaGC-LOM Phone L-1-433- 12�
Mailing Address 1 5 uQ-te..r ••oetA.sGC Rd
Ci VO.nc tb ocso State NG Zip code Z$ �6 S
Signature of Delegated Party
riindicating acceptance of
SignatoryAuthority:
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, Ske.r,o, (printed name),
have the authority to enter into this Agreement for
Zc,}er�cti o. .ana.\ 'Po. e Gow.Qasti (Owner/Organization Name).
I requestthat the DEMLR Storinwater 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/formy
organization and have authorityto act as a signatory for purposes of the NCDEQ's
electronic document systems.
By submitting this application,I, 'EkCr+A So r`de-s-s (printed name),have read,
understand, and accept the terms and conditions of the stormwaterpermit(s) for which I.
am the Responsible Official.
CC2re
Responsible.Official Signature
� �ec• Zl, 2-0a-3
Title Date
Stormwater Permit Delegation of Signato iy Autho rity Form
Page 3