NCG020843_SW Permit DOSA_20220127

v NC Department of Environmental Quality
wN` ` Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental Quality
Stormwater Permit Delegation of Signature Authority Forme
Directions are in red.
=t� 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 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 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:
Roy L. Etheridge, Jr.
Permit Number:
NCG020843
Responsible Official Title:
Owner
Email Address:
[e-mail]
[Phone:
252-202-8651
Mailing Address:
3908 Poor Ridge Road
City.
Kitty Hawk
State:
NC
I ZiP
27949
RECEIVED
AO 21.120H
DENR-LAND QUALITY
WORMWATER PERMiT'TINO
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:
Kenneth Elliott
Delegated Party Title:
Consultant
Delegated Party Organization:
Elliott Consultin
Email Address:
ken@kenobx,com
Phone:
252-339-9021
Mailing Address:
PO Box 112
City:
A dlett
State:
NC
I Zip:
27916
Signature of Delegated Party indicating
acceptance of Signatory Authority:
i
Date:
t2 _3 0 P--V ;�r I
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
Clty:
State:
1 Zlp:
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:
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 CPR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, I, Roy L. Etheridge, Jr. (printed name),
have the authority to enter into this Agreement for
Lee Septic and Land (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, Roy L. Etheridge, Jr. (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 Signa ure
Owner JA -72 d -�J
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3