NCG080760_Delegation of Signature Authority_20211202

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
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Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
This form shall be used to delegate signature authority from the permit Owner (Permlttee) 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 whichAvhom a permit has been issued, and may be an individual
or an organization such as a company orgovemment 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 far compliance with permit conditions.
Permittee:
ABF Freight System, Inc.
Permit Number:
NCG080760
Responsible Official Title:
Matthew Godfrey
Email Address:
[e-mail]
Phone:
479-785-6000
Mailing Address:
3801 Old Greenwood Road
City:
Fort Smith
state:
AR
Zip:
72903
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
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Stormwater Permit Delegation of Signatory Aalhority Forth
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, Matthew Godfrey (printed name),
have the authority to enter into this Agreement for
ABF Freight System Inc. (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, Matthew Godfrey (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Respon ible Official Signature
Vice President
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

Georgoulias, Bethany
From: Jean Heathcott <[e-mail]>
Sent: Wednesday, December 1, 2021 1:55 PM
To: Georgoulias, Bethany
Subject: [External] Stormwater Permit Delegation of Signature Authority Form
Attachments: Stormwater Permit Delegation of Signature Authority Form.pdf
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Report Spam.
Bethany,
Please see the attached Stormwater Permit Delegation of Signature Authority Form. The completed form is for our ABF
Freight System, Inc. Service Center located at 1165 NC Highway 66 South, Kernersville, NC 27284.
Please let me know if you have any questions.
Thanks,
Jean Heathcott I Supervisor, Real Estate Compliance I ArcBest® I p: 479.785.6027 1 c: 479.461-5053 1 arcb.com