NCG210028_SW Permit DOSA_20220531

t. STATf .
' NC Department of Environmental Quality
#�•^ter
Division of Energy, Mineral and Land Resources
NORTH CAROLINA
EnV&WWWft Ol Q=U:y
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 DEML.R 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.
Organization Name:
Responsible Official Name:
Responsible Official Title:J
Email Address:
:er Healthcare Corporation _
Marini
Director
[e-mail]
Phone: 1828_756_4151
Mailing Address: 165 Pitts Station Road
City: IMarion I State: INC I zip: 128752
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:
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:
Stephen Gouge
EHS Manager
NCG060030
[e-mail]
I Phone:
828-756-6608
65 Pitts Station Road
Mari n
I State: INC
I Zip: 128752
Stephen Gouge
EHS Manager
NCG210028
[e-mail]
I Phone:
828-756-6608
65 Pitts Station Road
Marion State:INC Zip: 28752
5hq 2n
Delegated Party Name:
Delegated Party Title:
Brian Valiquette
WWTP Supervisor
-
Permit Number:
NCG060030
Email Address:
Mailing Address:
brian [e-mail]
Phone:
828-756-6321
65 Pitts Station Road
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date: - - -
Marion
I State:
INC
Zip:
128752
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Delegated Party Name:
Delegated Party Title:
Brian Vali uette
WWTP Supervisor
Permit Number: _
NCG210028
Email Address:
[e-mail] Phone: [phone]
65 Pitts Station Road
Mailing Address:
City:
M
State:
INC
I Zip:
128752
Signature of Delegated Party indicatin
acceptance of Signatory Authority:
Date:
2 Y 20 A2.
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, Tim Marini
have the authority to enter into this Agreement for
Baxter Healthcare Corporation (Owner/Organization Name).
(printed name),
I request that the DI=MLR 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 attfor my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, Tim Marini (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
�x
Site Director
Title
Official Signature
:)( t'IA4 zc, �z
Date �
Stormwater Permit Delegation of Signatory Authority Form
Page 3