NCG060235_SW Permit DOSA_20220504

r , NC Department of Environmental Quality
u
Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental Quality
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
=> 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 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 for compliance with permit conditions.
Permittee: IUIIicYoung - Domino's Pizza LLC
Permit Number: INCGO60235
Email Address: [e-mail]
Mailing Address: 3100 Waterfield Dr
City: Garner
Phone [phone]
State: NC I ZiP: 27529
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.
ftR�
Delegated Party Name:
Ryon Resner
Delegated Party Title:
Director NC Supply Chain Center
Delegated Party Organization.
Dominos Pizza LLC
Email Address:
[e-mail]
Phone:
734-358-4589
Mailing Address:
3100 Waterfield Dr
City:
Gamer
I State:
NC
I Zip:
27529
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
4 K y-L.
Name:
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 Parry indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
City:
State:I 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 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, I, Uilic
have the authority to enter into this Agreement for
Domino's Pizza LLC
(Owner/Organization Name).
(printed 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, Ullic Young (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Resnonsible Official.
Reivponsible Offici I Si ture
RVP Supply Chain opera ion
Title
5l4ho zz
DA
Stormwater Permit Delegation of Signatory Authority Form
Page 3