24 - Delegation of Signature Authority Form

NC Department of Environmental Quality

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 whichAvhom a permit has been issued, and may be 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 122. 22, summarized below: 2
e Foracorporation, 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.
¢ Fora partnership or sole proprietorship, the Responsible Official shall be a general partner or the proprietor, respectively; or
° Fora 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: City of Raleigh
Permit Number: NCS000245
Responsible Official Title: _|City Manager
Email Address: [e-mail] _| Phone: |919-996-3070
Mailing Address: 222 W. Hargett Street
City: Raleigh State: INC | Zip: |27601
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: IS. Wayne Miles
Delegated Party Title: Stormwater Program Manager
Delegated Party Organization: City of Raleigh
Email Address: [e-mail] | Phone: |o19-996-3964
Mailing Address: P.O. Box 590 West Hargett Street
City: Raleigh. /hstate: Inc | Zip: [27601
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
em shy \ U
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
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, |, Marchell Adams-David (printed name),
have the authority to enter into this Agreement for
City of Raleigh (Owner/Organization Name).
| request that the DEMLR Stormwater Program include the persons listed in Part A of this form signatory authority for the above-named permit.
| acknowledge that |, 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, |, Marchell Adams-David (printed name), have read, understand, and accept the terms and conditions of the stormwater permit(s) for which | am the Responsible Official.
Responsible Official Signature
City Manager ho (2022
Title Date
Stormwater Permit Delegation of Signatory Authority Form Page 3
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