NCG081008_SW Permit DOSA_20220331

NC Department.of Environmental Quality
Division of Energy, Mineral and Land Resources
P40RTH CAROLINA
fnrironmrmnd Qtee1[ly
Stormwater Permit Delegation of Signature ..Authority Form
Directions are. in red.
This form shall be used to.delegrate sigrna.tureauthority 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.
-L* The permit Owner is the. legal'entity to which1whom a permit has been issued, and may 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 12Z22 summarized
below:
• For a corporation, the Responsible Official shall be a president, secretary, treasurer, .or vice-
presrdent in charge of a principal business function, or another individual wh.o performs similar
functions for the corporation, or the manager of one or more manufacturing, production, or operating
facilities who is authorized to snake 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 [CitylCounty Manager] or ranking elected official [Mayor].
=5 Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for.complience with permit conditions,
Stormwater Delegation of Signature Authority Farm
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A.. Persons to Receive Signatory Authority
zz> The signatures. of the persons listed below indicates.their acceptance .of signatory authority.
'•: pefegated:.Party PVarrie::::::`:;':::.':::
Delegatec�`.Party Title ...:::::`:.:':.
.-
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:Email. Address::': " Phone,
> lvla]irig Address:
.................
Signature.of.belegated'Party fndicaf.'ing
accepiarice:6f 5ignatoiji:AuUia�fy;:::; :.-.:.
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, \ rIA VJ f bOyj f 7�O (printed name),
have the authority to enter into this Agreement for
_'S�eYO� W 4 Pc]11-7` 1 10 K f W— - . (Owner/Organization Name).
1 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, 1, J-1 in w(op"i (printed name),
have read, understand, and accept the terms and conditions of the stormwater permits) for
which I am the Responsible Official.
Respooble O ial Signature.
�PV(xlaN-i�ac�
Title Date
5tormwater Permit Delegation of Signatory Authority Form
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