NCG050334_SW Permit DOSA_20240205

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ROY COOPER s y
Governor
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ELIZABETH S.BISER n.frt_ �
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Secretary `r'aw�v0,
DOUGLAS R.ANSEL NORTH CAROLINA
Interim Director Environmental Quality
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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: NCDEMLRStormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity National Pipe and Plastic
Responsible Official Name National Pipe and Plastic
Responsible Official Title: Matt Siegel
Email Address: [e-mail] Phone [phone]
MailingAddress 1 N. Page Ave.
City Endicott State NY Zip code 13760
.D --,_ North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
512 North Salisbury Street 11612 Mail Service Center I Raleigh.North Carolina 27699-1612
t:;l:#i11 CAFC}=A
OePartMentaEm ALL CI.N\ /en.' 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 Kate Robbins
Delegated Party Title EHS Manager
Permit Number(s) NCG050334
Email Address: [e-mail] Phone [phone]
Mailing Address 9609 West Market Street
City Colfax State NC Zip code 27235
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
MailingAddress
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 2

C. User Account Information
Include the following information for all User(s) listed in Part B. Attach additional pages if you
need more space.
Click on one or more of the two access roles available: Facility Administrator and/or
Submitter.
• If the user enters data and submits report on behalf of the facility, then the Submitter
role should be requested. This role is automatically approved to enter and certify the
data. This person must have signatory authority for the permit.
• If the user is the person responsible for managing user information for the facility/permit,
then the Facility Administrator role should be requested. The Facility Administrator
user can be assigned by the Responsible Official or can be assigned at the time of
registration by the Stormwater eDMR Administrator. Note: If this person is responsible
for submitting eDMR reports, then they must have signatory authority for the permit.
User Account Information Permit Number(s)
Request Access Role: nSubmitter ❑✓ Facility Administrator
Name: Kate Robbins Title: EHS Manager
Do you already have an eDMR ]Yes ❑✓ NO If Yes, Phone:
account? I I User ID
Organization: National Pipe and Plastics
Email Address: [e-mail]
Mailing Address: 9609 West Market St.
City: Colfax State: NC Zip: 27235
User Account Information Permit Number(s)
Request Access Role: nSubmitter n Facility Administrator
Name: Title:
Do you already have an eDMR If Yes,
account? ❑Yes No User ID Phone:
Organization:
Email Address:
Mailing Address:
City: State: Zip:
User Account Information Permit Number(s)
Request Access Role: ESubmitter ]Facility Administrator
Name: Title:
Do you already have an eDMR Ekes ❑No If Yes, Phone:
account? User ID
Organization:
Email Address:
Mailing Address:
City: State: Zip:
Stormwater Electronic Reporting Registration Form
Page 3

D. Electronic Signature Agreement Conditions
To receive and accept the required electronic signature credential, consisting of a User ID and
password, issued by the North Carolina Department of Environmental Quality (NCDEQ) in order
to sign electronic documents submitted to NCDEQ's Electronic Document Systems and to
receive electronic documents from NCDEQ's systems;
The Responsible Official and other User Account(s) (if applicable) named in this form do
herby:
1. Understand that this Electronic Signature Agreement requires me to submit electronic
documents to NCDEQ's approved eDMR system under the authorized program in lieu of
paper submissions.
2. Understand that this Electronic Signature Agreement requires me to accept electronic
transmissions, in lieu of paper transmissions of all permits, permit modifications,
authorizations to construct, and any other correspondence related to reviewing and
processing permits from NCDEQ. This authorization will not become effective until NCDEQ
establishes a system for processing electronic documents; I am notified in writing from
NCDEQ that use of the electronic systems has officially been initiated; and North Carolina
rules and statutes are changed to allow the implementation of electronic submittal and
acceptance of documents.
3. Understand that this Electronic Signature Agreement requires me to submit electronic all
necessary information for processing of NPDES application including information for renewal
of existing permits, modification to existing permits, and applications for new discharge
permits. The submittals may include all necessary applications and supporting documentation
to NCDEQ's approved system for electronic submittals in lieu of paper submissions. This
authorization will not become effective until NCDEQ establishes a system for processing
electronic documents; I am notified in writing from NCDEQ that use of the electronic systems
has officially been initiated; and North Carolina rules and statutes are changed to allow the
implementation of electronic submittal and acceptance of documents.
4. Understand that this Electronic Signature Agreement requires me to accept electronic
submissions, in lieu of paper submissions, of all Notices of Deficiency, Notices of Violation,
Civil Penalty Assessments, and any other correspondence related to compliance with federal
and state water quality laws and regulations that might be sent by NCDEQ. This authorization
will not become effective until NCDEQ establishes a system for processing electronic
documents; I am notified in writing from NCDEQ that use of the electronic systems has
officially been initiated; and North Carolina rules and statutes are changed to allow the
implementation of electronic submittal and acceptance of documents.
5. Agree to protect both the electronic signature credential, consisting of my User ID and
password, and security questions and answers, from compromise and from use by anyone
except me. Specifically, I agree to maintain the secrecy of my electronic signature credential
and security questions and answers; I will not divulge or delegate my credential or security
questions and answers to any other individual; I will not store my credential or security
questions and answers in an unprotected location; and I will not allow my electronic signature
credential or security questions and answers to be written into computer scripts to achieve
automated log-in.
6. Understand and agree that I will be held as legally bound, obligated, and responsible for the
use of my electronic signature as I would be using my hand-written signature.
7. Understand that I will be informed through my registered email address whenever my User ID
or password has been modified.
Stormwater Electronic Reporting Registration Form
Page 4

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 Siegel (printed name),
have the authority to enter into this Agreement for
National Pipe and Plastics
(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 Siegel (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
President r Z Z
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3