NCG190007_SW Permit DOSA_20220531

ce.r NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
frtrirnrtmrnrrtf lludlely
Stormwater Permit Delegation of Signature Authority Farm
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/whore 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, su►nmarized
below:
• For a corporation, the Responsible Official shall be a president, secretary, treasurer, or vice-
president in charge of a principal business fanction, 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
Is For a municipality, Stato. Federal, or other- public agency, the Responsible Official shall be either a
principal executive officer- [CitylCounty Manager] or ranking elected official [Mayon.
Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
Organization Name: White River Marine Group, LLC
Responsible Official Name: Dan Hoy
Responsible Official Title: Director of Facilities
Email Address: _ [e-mail] I Phone: [phone]
Mailing Address: 2500 E. Kearney St,
City: Springfield State: �MO I zip: 165803
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: Blake Pruitt
Delegated Party Title: _ Divisional EHS Manager
Permit Number: NCG190007
Email Address: T blakepruitt@whiterivernig.c❑m ` Phone: [phone]
Mailing Address: 2500 E. Kearney St
City: Springfield/ r, I State: IMO I Zip: I65803
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date: 15131
Delegated Party Name:
j Delegated Party Title:
Permit Number:
Email Address:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
j Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Mailing Address_ :
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
I Phone: 1
State: I I Zip:
IPhone:
State: Zip:
Phone:
state -
Storrnwater Permit Delegation of Signatory Authority Form
Page 2

B. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 1 22.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, I, Dan H
have the authority to enter into this Agreement for
White River Marine Group, LLC
(Owner/Organization Name).
(printed name),
I request that the ❑EMLR Stormwater Program include the persons fisted 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, Dan Hoy (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which l am the Responsible Official.
Responsible Official Signature
Director of Facilities
5131 /22
Title Date
5tormwater Permit Delegation of Signatory Authority Form
Page 3