NCG100023_SW Permit DOSA_20220620

h
� This form shalldelegategpuf Owner (Permittee) to
another party. Only the Responsible O�aal defined below mays ' permit applications and
eports required by the permit (such as Data Monitoring Reports and Annual Reports) until is
orm is cvmpie�ea gnu auu�rnucd �� t
compliance.
5TA'�
-
Mt
104
1 � �
NORTH CAROLINA
EnvironmenfW QuaUly
NC Department of Environmental Quality D
ivision of Energy, Mineral and Land Resources
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
fsignature authority does not relieve the Permit Owner from the responsibility tor permit
be used to signature autnonry rrvm �r�e <���t
submit
e DEMLR Stormwater Program. Please note that de�egaung
—, The permit Owner is the legal entity to which/whom a permit has been issued, and may be an individual
t;,,,, curh ac a �„mnar,v nr government aciencv., Every Owner rs required to have a
v� art veya"n�uuv�i - ..
tore authority requrremen
Official who meets the legal signa
below:
For a corporation, the Responsible Official shall be a president, secretary, treasurer, or vice -
;A ,in in charge of a principal business (unction. or another individual who performs similar
functions for the corporation
faciliti
operating
i
ts in 40 CFR 122.,2.2, summarized Responsible
or the manager or one ur n,uie rr�auuia�iu"uiy, Nfv�u�.,
es who is authorized to make management decisions about the facility operation.
• For a patInership or sole proprietorship. till
proprietor, respectively; or
e Responsible Official shall o'e a general partner or the
• 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: too0C eo1_(�C--
Responsible Official Name: CAA�-�n
Responsible Official Title: v Pry
Email Address: --- X111111('�'S� rnGn imJv�o�orc�o Phone : ��{7$2.
Mailing Address-.J��S Z—
City: R�,�� (� m6L State: Zip: Z? 3 1 7
Delegation of Signature Authority Form
Page 1
f Stormwater

A. Persons to Receive Signatory Authority
The signatures of the persons listed below indicates then acceptance of srgnalory authority
_Delegated Party N2me-
Delegated Party Title -,Permit Number:
Email Address.*
I--- ------ am- -
� Melling Address-
city -
Signature of Delegated Party indicating
'p acceptance of Signatory Authority-
Date -
Delegated Party Name-.
r Delegated Party Title:
['Permit Number:,
Email Address:
Mailing address:
City.
Signature of Delegated Party indtcating
acceptance of Signatory Authority:
Date:
Delegated Party Name
Delegated Party Title: -,---
Permit Number: _
Email Address;
� Mailing Address:
CityO
Signature of Delegated Party indicating
acceptance of Signatory Authority'.
Date
Rain Davis
,Senior Stormwater Project Manager .�
NCG �00023
__ -- - rdavis c�maaonline.com Phone: 919
I �,
409 Rooers View Ct
-971-6345
Raley h[State: INC [ZiPA 127610
6/1/2022
0
J�3 - -------
C'vt � �r- �t Oqkl C� +�.t iwC�Lw& r Phone' � _ SLi3,jqt 3 6�
�1 vq (2 04v rt S v � _ .� _ ....... jjO"'FPNPjPENkNF�
: 4 ..��.' I S fate: � rrt � Zip:
--- . _
Phone
State -
Delegated Party Name:
Delegated Party TV&
Permit Numbers. _ — --
Email Address., _ � Phone:
Mailing Address:
City' State: I
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Dele
gation of Sign
Page 2
story Authority Form
Zip:
i

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,
have the
01j
%. %do M�L H 4
authority to enter into this Agreement for
Mo n rr Cr) 7VIC
(Owner/Organization Name).
(printed name),
l 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.
I
By submitting this application, I, _
have read, understand, and acre
pt the terms and conditions of the storm
which I am the Responsible Official.
sprinted name),
water pe it(s) for
0
Responsible 06ivcial Signature
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3