NCG060217_SW Permit DOSA_20220706

r NC Department of Environmental Qualq
•`". ,� Division of Energy, Mineral and Land Resources
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tormwat.et Periviil. Delegation of SignaUire Authmity Fowri
Directions are in red
y This form shag 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 far 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 far compliance with permit conditions
Permittee: Adrian Mitchell
errnit Number. NCG06217
Responsible Official Title: Vice President Operations
Email Address: amitchell cr smithfield.c Phone--_] 816-500-4985
Mailing Address: 200 Commerce Street
City: Smithfield I State jVk zip E23430
StormErvater Deiegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
The signatures of the persons fisted below indicates them acceptance of signatory authority
Delegated Party Name:
Brandon Farley
Delegated Party Title:
Project Engineer
Delegated Party Organization:
Smithfield Packaged Meats - Wilson_
I j (� r Phone: 252.
�w+, c�r .r.r.� i M-Zr i
12461 Wil& Blvd.
Wilson _ State: NC Zip: 2
Email Address:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:x-
Delegated Party Name:
David Hoffman
Delegated Party Title:
Plant Manager
Delegated Party Organization:
Smithfield Packaged Meats - Wilson
Email Address:
t
Phone:
Mailing Address:
2401 Wilco Blvd.
City:
Wilson
I State:
INC I ZIP:
I
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
6—/—/4/---
Delegated Party Name:
-- — _-
Delegated Party Title:
Delegated Party Organization.
Email Address:
Q Phone:
7
Mailing Address:
Z14pij
City:
U•6
State:
G zip:
Z?
Signature of Delegated Party indicating
acceptance of Signatory Authority.
-11� `
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

S. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR QZ22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, 1, Adrian Mitchell (printed name),
have the authority to enter into this Agreement for
Smithfield Packaged Meats Corp. (Owner/Organization 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, Adrian Mitchell (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
Vice President, Operations
Title
�pt
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3