NCS000349_Delegation of Signature Authority_20220112

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NC Department of Environmental Quality
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NORTH [AROIrnlA 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 sig naiure authority from the permit owner (permhyee) to
anotfrer part+. Only the Responsible Official defined below may submit permit applications and
Worts required by the permit (such as Data ftnitodng Reports and Annual reports) until this
form is completed and sub► !tW to the DEXLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility for permit
compliance.
=> The p8rrrrit Owner is the legal entity to whichlwhom a permit has ;been issued, and maybe an individual
or an organization such as a company orgovernment 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 mane management decisions about the facility operation.
For a ;partnership or sale 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 [CitylCounty Manager] or ranking elected official [Mayor].
Even if delegated signatory authority has been delegated to another individual, the Responsible Offlcj,3j
rstalns responsibility for compliance with permit conditions.
Ferrnittee: North Carolina Renewable Power - Lumberton, LLC
Permit Number: NCS000349
Responsible Official Title: Carey Davis - Executive Vice President - Georgia Renewable Power
Email Address: [e-mail] Phone: (2Q5) 403-4273
Mailing Address: 2100 Southbridge Parkway - Suite 540
City: Bermingham State: JAL IZip: 35209
Stormwater Delegation of Signature Authority Fora
Page 1

A. Persons to Receive Signatory Authority
The signatures of the persons listed below indicates their acceptance of signatory authority
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
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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, 1, (printed name),
have the authority to enter into this Agreement for
North Carolina Renewable POWer- Lumberton, LLC
(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.
1 acknowledge that 1, 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, (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I ar he Responsible Official.
Res or ible Official Signature
Title Date
Stormwater Permit Delegation of Signatory Authority Form
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