NCG080991_SW Permit DOSA_20220331

NC Department of Environmental Quality
Division. of Energy; Mineral and Land Resources
NORTH CAROUNA
rnV&V=Cnraf Quality
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
This form shall be used to delegate signatureauthority from .fhe.permit Owner (Permittee) to
another part}: 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 Ownerfrom the responsibility for permit
compliance.
=> The permit Owner is the: legal entity to which/whom a permithas been issued, :and. maybe an individual
or an.organization: such as a. company or government agency. Every Owner is requiredto have. a
Responsible. Official who meets the legal signature authority requirements. in 40 CFR 122.22,..summarized
below.
• Fora 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 [CitylCounty 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.
5tormwater Delegation. of. 5ignature Authority Fmrn
.Page 1.

A. Persons to Receive Signatory Authority
==:, The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Todd Wilson
Delegated Party Title:
Director of Environmental Services
Delegated Party Organization:
The SEFA Group
Email Address:
[e-mail]
I Phone:
803-520-9000
Mailing Address:
217 Cedar Road
City:
Lexington
State:
I SC I Zip:
29073
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Ac
Date:
03/25/2020
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 Parry 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: 77
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,
J f Mtllj 115 t t-
have the authority to enter into th is Ag reem ent fo r
T7tAN 0/2-i-4nv,a itJL- (OwnerlOrganization Name).
(printed name),
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 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, _ �JlM W(bow (printed name),
have read, understand, and accept the terms and conditions of the Stormwater permit(s) for
which .1 am the Responsible Official.
Respoosible/C4ficial Signature
Title
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3