NCG060295_Delegated Signature Authority_20210706

NC Department of Environmental Quality
Division of Energy, Mineral and Land
��� NORTH CAROLINA
Environmental Quality
JUL 0 6 2021 Fia)
Stormwater Permit Delegation of Signature Authority Form
DENR-LAND QUALITY
Directions are in red. STORMWATER PERMITTING
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 govemment 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: Mountaire Farm_ s of North_ Carolina Corp
Permit Number: NCG060295
Responsible Official Title: President
Email Address: [e-mail]
Mailing Address:
City:
PO Box 1320
Millsboro
Phone: [phone]
State: IDIE I Zip: 119966
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
Uelegated Party Name: David Kirby
Delegated Party Title: Sr Director Processing Operations
Delegated Party Organization: Mountaire Farms
Email Address: [e-mail] I Phone:
Mailing Address: PO Box 320
city: Siler City State: NC Zi
Signature of Delegated Party indicating p
acceptance of Signatory Authority.
Date: �2A2
Delegated Parry Name:
David white
Delegated Party Title:
Director Processing Operations
Delegated Parry Or anization:
Mountaire Farms
Email Address:
[e-mail] Phone: [phone]
Mailing Address:
PO Box 339
City:
Signature of Delegated Party indicating
Lumber Bridge State: NC Zip: 28357
acceptance of Signatory Authority.
Date:
uelegated Party Name:
Delegated Party Title:
Delegated Parry Organi
Email Address:
Mailinq Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority.
Date:
Name:
Title:
Email Address:
Mailing Address:
City.
Signature of Delegated Party indicating
acceptance of Signatory Authority.
Date:
Phone:
State: I I Zip:
Phone:
State:
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, Philip Plylar (printed name),
have the authority to enter into this Agreement for
Mountaire Farms of North Carolina Corp (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, Philip Plylar (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 Sign ure
President
Title
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3