NCG030170_Delegation of Signature Authority_20210708

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RECEIVED NC Department of Environmental Quality
JUL 0 8 2021
NORIH FARO.JNA
DENR-LAND QIJgLIl�tvision of Energy, Mineral and Land Resources
EnvironmentoI Quutiq STORMWATER PERMITTING
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:
IMC-MetalsAmerica, LLC
Permit Number:
NCG030170
Responsible Official Title:
Brian Freeman, Technical Manager
Email Address:
[e-mail]
Phone:
7044716550
Mailing Address:
135 Old Boiling Springs Road
City:
Shelby NC
State:
NC I
Zip
28152
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:
Claude Dube
Delegated Party Title:
President
Delegated Party Organization:
IMC-MetalsAmerica, LLC
Email Address:
[e-mail]
Phone:
7044716587
Mailing Address:
135 Old Boiling Springs Road
City:
Shelby
State:
NC
I Zip:
28152
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
July 7, 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, Brian Freeman
have the authority to enter into this Agreement for
IMC-MetalsAmerica, LLC
(Owner/Organization Name).
(printed 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, Brian Freeman (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Officiqj/
Responsible Official Signature
Technical Manager July 6, 2021
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3