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HomeMy WebLinkAboutNCS000442_Rocky Mount DOSA Form_20210222�ae'r STrVlE ° NORTH CAROLINA EnrtironM#fe101 Qre•ttty NC Department of Environmental Quality Division of Energy, Mineral and Land Resources ° EVE, D Stormwater Permit Delegation of Signature Authority Form,,,,., l I s ►t10 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 Stormwater 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: City of Rocky Mount Permit Number: NCS000442 Responsible Official Title: Rochelle Small- Toney, City Manager Email Address: rochelle.small-toney@rockymountnc.gov Phone: 252-972-1331 Mailing Address: 331 S Franklin St City: Rocky Mount State: NC I Zip: 27802 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: William B. Kerr Delegated Party Title: Public Works Director Delegated Party Organization: City of Rocky Mount Email Address: brad.kerr@rockymountnc.gov I Phone: 252-972- Mailing Address: 331 S Franklin St City: Rocky Moun I State: INC Zip: 27802 Signature of Delegated Party indicating acceptance of Signatory Authority: Date: Delegated Party Name: Donald Perry Delegated Party Title: Assistant City Engineer Delegated Party Organization: city of Rocky Mount Email Address: donald.perry@rockymountnc.gov I Phone: 252-972-1122 Mailing Address: 331 S Franklin St City: Rocky Mount State: NC Zip: 27802 Signature of Delegated Party indicating acceptance of Signatory Authority: e r Date: 2 2 Delegated Party Name: Scott Miles Delegated Party Title: Stormwater Engineer Delegated Party Organization: city of Rocky Mount Email Address: scott.miles@rockymountnc.gov Phone: 252-972-1340 Mailing Address: 331 S Franklin St City: Rocky Mount I State: NC I Zip: 27802 Signature of Delegated Party indicating acceptance of Signatory Authority: Date: 2.10 -21 Delegated Party Name: Delegated Party Title: Delegated Party Organization: Email Address: Phone: Mailing Address: City: State: Zip: 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, Rochelle Small -Toney (printed name), have the authority to enter into this Agreement for City of Rocky Mount, NC (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, Rochelle Small -Toney (printed name), have read, understand, and accept the terms and conditions of the stormwater permit(s) for which I am the Responsible Official. nsible Official Signature City Manager Title A/it (A_l Date Stormwater Permit Delegation of Signatory Authority Form Page 3