NCG060069_SW Permit DOSA_20220726

- NC Depwtnw t of Environmental Quality
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Division of Energy, Mineral and Land Resources
NORTH CAROLINA
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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 Stonnwater 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 12_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:
Email Address: T
Mailing Address:
City:
Procter & Gamble Manufacturing
Miguel A. Valdovinos
Plant Manager
.com
Bryan Park Road
is Summit
Phone: [phone]
Stormwater Delegation of Signature Authority Form
Page 1
NC

A. Persons to Receive Signatory Authority
The signatures of the persons listed below indicates their acceptance of signatory authority_
Dele ed Pa Name: Apn Malay _
t
De d Pa Title: Sits Environmental Leader _
8.. rhr ron
Permit'Number. NCOMM9 +
Email Address:
4Y Way al®p9 corn T Phone: s3s OU4528
Malting_ Address: 6200 Bryan Park Road
[CRY: amwns summit State: He Zip:
Signature of Delegated Party indicating i
acceptance of Signatory Authority.
DYate: , i s-I�v -a
Dehigated Party Name;
_Delegated Party Title:
Permit Number.
Email Address:
Mailing Address:
_City:
Signature of Delegated Party indicating
aoceptance 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 Author* r.
Date:
Delegated Party Name: _ T
Delegated Party Title T
Permit Number t
Email Address:
Mailing Address:
City:
r5lgnature of Delegated Party Indicatmg
acceptance of Signatory Autho
Date:
Phone:.�I .,
State Zio.
Phone: J — - -
I State_ I_ I Zip:._
Stomnwater Permit Delegation of Signatory Authority Form
Page 2

S. 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, MrgUel A. yaba—
have the authority to enter into this Agreement for
Procter E Gamble Manufacturing
(Owner/Organization Name).
(printed name),
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 attfor my organization
and have authority to act as a signatory for purposes of the NCDEO's electronic document
systems.
BY submitting this application, I, MiULW A V&%Jo")- • (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
Plant Manager
Title
OS 113IWI
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3