NCG050368_SW Permit DOSA_20240131

ROY COOPER ` ��,
Governor t
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 Latham Pool Products Inc
Responsible Official Name Matt Rowe
Responsible Official Title: VP of E H S
Email Address: [e-mail] Phone [phone]
Mailing Address 787 Watervliet Shaker Road
City Latham State NY Zip code 12110
North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
000��� 512 North Salisbury Street 11612 Mail Service Center Raleigh,North Carolina 27699-1612
.a ...,t,,a„.„.,...,,,,:., 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 Theresa Elliott
Delegated Party Title Environmental Compliance Manager
Permit Number(s) NCG050368
Email Address: [e-mail] Phone [phone]
Mailing Address 40119 CR 54 East
City Zephyrhills State FL Zip code 33540
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
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, Matt Rowe _ (printed name),
have the authority to enter into this Agreement for
Latham Pool Products Inc (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, Matt Rowe (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
VP of EHS / 9A�
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

-1
— Ocv - -1Q
i
� pp�m M—,6)c.n ZQ Zr pD=.Z7
I �D (7m
�� — DC NC7MmZ TxiG)
-7r=�� { #J —_ o N 2 m m-1 z=m Z
fra � 'A "r TZ�mr �c� cnncn—
�� = o rn r N to -< nrm
D_ Zpr
GJ7 _ o 'C7 D O D N m Z A r n
Cn O ' xi-o r N ca s m,
_ V)Mtn— O c,% D---
OCI,O �r Y w — C7�0C m 73 c� m
mCPOo rn�n� D
>
comlmcn m w
O r �m0,�
Cfl m Z O -0 rn
ti —1 X .0
p m
I —Ss; 1- — w y n x
M _ 1— 0—1-
X O gt- ctlis m —0 n
Z A
7i m mom
/�Iy1 LLMM�J J _=r`n
�I Z07 N
Cl) En rn A
V+ En 1� A
w U
CO
01
v N
� • rnm
0 L 0
d241024011001uv e
7:1 IV 583J5/EC2B/9AE3
After printing this label:
CONSIGNEE COPY-PLEASE PLACE IN FRONT OF POUCH
1.Fold the printed page along the horizontal line.
2.Place label in shipping pouch and affix it to your shipment.
Use of this system constitutes your agreement to the service conditions in the current FedEx Service Guide,available on
fedex.com.FedEx will not be responsible for any claim in excess of$100 per package,whether the result of loss,damage,
delay,non-delivery,misdelivery,or misinformation,unless you declare a higher value,pay an additional charge,document
your actual loss and file a timely claim.Limitations found in the current FedEx Service Guide apply.Your right to recover from
FedEx for any loss,including intrinsic value of the package,loss of sales,income interest,profit,attorney's fees,costs,and
other forms of damage whether direct,incidental,consequential,or special is limited to the greater of$100 or the authorized
declared value.Recovery cannot exceed actual documented loss.Maximum for items of extraordinary value is$1,000,e.g.
jewelry,precious metals,negotiable instruments and other items listed in our Service Guide.Written claims must be filed
within strict time limits,see current FedEx Service Guide.