NCG050072_Owner Affiliation Update_20210312

McCoy, Suzanne
From: Eric Houston <[e-mail]>
Sent: Friday, March 12, 2021 8:38 AM
To: McCoy, Suzanne
Cc: Cliff Wilson
Subject: [External] New Signature Authority Delegation
Attachments: Stormwater Permit Delegation of Signature Authority -Carpenter Co.pdf
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Hi Suzanne,
Tom Dunston, our division manager, has retired.
Cliff Wilson has been promoted to this division manager position.
Please find the signature delegation paperwork attached to accommodate this change.
Carpenter Company -Conover, 2009 Keisler Road SE, Conover, NC 28613
Our permit number is NCG050000.
Our certificate of coverage number is NCG050072.
I will send you the hard copy via certified mail today.
Thanks,
Eric Houston
Carpenter Company
Conover Division
828.464.9470 x-4446
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1

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CAROLINA
EnWmn enfat Qaaffy
Stormwater Permit Delegation of Signature Authority Form
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:
Carpenter Company -Conover
Permit Number:
NCG050000
Responsible Official Title:
Cliff Wilson, Division Manager
Email Address:
[e-mail]
I Phone:
828-464-9470 ext. 4474
Mailing Address:
PO BOX 879
City:
Conover
I State:
NC
I ZiP:28613
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:
Cliff Wilson
Delegated Party Title:
Division Manager
Delegated Party Organization:
Carpenter Company
Email Address:
[e-mail]
I Phone:
828-464-9470
Mailing Address:
PO Box 879
City:
Conover
I State:
INC
I Zip:
28613
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Ot
i
Date:
3/12/2021
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:
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:
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, InlLZOr_1 (printed name),
have the authority to enter into this Agreement for
CAfzFFIS lC CO — C)Ndl,�[Z tWI 90(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 attfor my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, G.l-'� (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
r-
Signature
CAf?4�cn�12_-C?�NoVG2 pNISgN MANPGS(Z-ZL
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3