NCG060108_SW Permit DOSA_20220513

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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 which/whom 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:
• 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:
Butterball, LLC
Permit Number:
NCG 060360 060108 060333 in order belo,
Responsible Official Title:
Director, Environmental Affairs & Sustainabilit
Email Address:
lruffin(D-butterball.com
Phone:
919-397-2347
Mailing Address:
One Butterball Lane
City:
Garner
State:
NC
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.
Delegated Party Name:
VVanna Kicnarason
Delegated Party Title:
tnvlronmental Manager
Delegated Party Organization:
BuiterDall - Ram=
Email Address:
WriCnara50ntp1Duitel Phone:
y"I U-5b54i'i5b
Mailing Address:
'WOO C. Gentral Ave.
City:
Kamm
State:
INu zip:
LtS.i ! b
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
JOsn baicnelOr
Delegated Party Title:
Superintendent - Utilities
Delegated Party Organization:
butierbail ME Olive VVVV I r
Email Address:
JDaicneior CVDuiierD"
Phone:
y`[y-JL"I -yUZb
Mailing Address:
"I o2b Darner Vnapel l:a.
City:
ivii. uiive
State: INI.
zip:
'Z0000
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
I erry Iviercer
Delegated Party Title:
Min Manager
Delegated Party Organization:
butterbail i urKey reea iviin
Email Address:
irnercer CUDunerban.
Phone:
�rl U-b'jS-mlwl
Mailing Address:
5bU4 i urKey t1Wy.
City:
i urKey
State; 11NUI
Zip:
IZOJUJ
Signature of Delegated Party indicating
acceptance of Signatory Authority;
Date:
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Emall Address: I
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

A. Persons to Receive Signatory Authority
=, The signatures of the persons listed below indicates their acceptance o� signatory authority.
Delegated Party Name:
VVanaa rxicnar❑Sor1
Delegated Party Title:
Cnvironmerlial IVlana
er
Delegated Party Organization:
pauerDall - KaeTor❑
Email Address:
wricnar❑Sorl(G)DUiiel
hone:
yJ] U-0004000
Mailing Address:
'I UUU t_. uerliral Ave.
City:
KaeTor❑ I
State: Nuzip:
Zbo t o
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
josh Esatcnelor
Delegated Party Title:
SUperlriienaeni - UII11
IeS
Delegated Party Organization:
BuilerDa11 iva. UINe V
VV I r
Email Address:
jDaicfleior(q,)DUiierDC
hone:
y"I y-yL"I-JULb
Mailing Address:
I t526 Garner unapel
❑.
City:
mi. uive
tate:
11 U1
Zip:
Z0600
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
- L /
Delegated Party Name:
I erry IVlercer
Delegated Party Title:
ivilm Manager
Delegated Party Organization:
bulnerDall I urKey re
❑ Null
Email Address:
imercer C1JDuiLerDall.
hone:
Mailing Address:
56134 1 OrKey Hwy.
City:
I UrKey
I State:
IVL. zip:
ZO J. J.5
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
hone:
Mailing Address:
City:
I State:
I
Zip:
Signature of Delegated Parry indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of Signatory
Page 2
A& ority Form

A. Persons to Receive Signatory Authority
=> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
vvanQa KlcnaraSon
Delegated Party Title:
Environmental Manager
Delegated Party Organization:
t Onemall - Kaerora
Email Address:
wricnaraSon�DUitel Phone:
J"I U-5b54Z555
Mailing Address:
I UUU E. Central Ave.
City:
Kaerora
State:
IN U
I Zip:
Z00 / b
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
JOSn baicnew
Delegated Party Title:
-Supennienclem - UilllileS
Delegated Party Organization:
tsuiterDall Pa. Ullve vvvv i r
Email Address:
JDaicnew(a),loutierIDEJ Phone:
I J"I J-:JL"I -JULb
Mailing Address:
I bzo Garner Gnapel Ka.
City:
iva. uive
I State:
I IVU
Zip:
L?J jt)O
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
I erry IVlercer
Delegated Party Title:
IVIIII Manager
Delegated Party Organization:
butierDall i urKey reea Mill
Email Address:
imercer(U')DutterDall.
Phone:
J'I U-b�S-byy I
Mailing Address:
=04 i urKey rlwy.
City:
I u rKe
State:
IV C�
Zip:
Lt5.5y.5
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, I, LanKTOra KUTTIn
have the authority to enter into this Agreement for
✓� �u (�. L.LC (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, Lawora KUTTIn (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Responsible Official Signature
U: re�lor C I 2-2
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

DOSA Information for Butterball, LLC
Permit Numbers:
NCG060360 —Wanda Richardson
NCG060333—Terry Mercer
NCG060108 —Josh Batchelor