NCG030711_SW Permit DOSA_20220801

'* V
NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CAROUNA
Cn v[rcnmrn rot Quali ry
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 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 FCitylCounty Manager] or ranking elected official [Mayor].
Even if delegated signatory authority has been delegated to another individual, the Responsible ❑fficial
retains responsibility for compliance with permit conditions.
Organization Name:
Robert Bosch Tool Corporation
Responsible Official Name:
Pedro Fondevila
Responsible official Title:
Plant Manager
Email Address:
Pedro. [e-mail]
I Phone
704-718-6091
Mailing Address:
1980 Indian Creek Road
Lincolnton State: NC Zip: 28092
City:
Stormwater delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
=> The signatures of the persons listed belovr indicates their acceptance of signatory authority.
Delegated Party Name:
Kasey Wattley
Delegated Party Title:
HSE Professional
Permit Number.
NCG030711
Email Address:
[e-mail]
I Phone:
704-691-8636
Mailing Address:
1980 Indian Creek Road
City:
Uncolnton
I State:
NC
I Zip:
12,9092
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Z
Delegated Parry Name:
Delegated Party Title:
Permit Number:
Email Address:
Phone.
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority.
Date:
Delegated Party Name:
Delegated Party Title. -
Permit Number.
Email Address:
Phone:
Mailing Address:
City:
state:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number:
Phone:
Email Address:
Mailing Address:
City:
state:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of signatory Authority Form
Page 2

D. 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.
Pedro Fondevila (printed name), have the authority to enter into
this Agreement for Robert Bosch Tool Corporation (Owner/Organization Name),
l request the NCDEQ grant the Submitter(s) named in Part B of this form an electronic signature
credential to submit and accept documents electronically on behalf of my organization.
I acknowledge that I, and the individual(s) named in Part B of this form, work attfor my
organization and have authority to submit and accept electronic documents and act as a
signatory for purposes of the NCDEQ's electronic document systems.
By submitting this application, 1, Pedro Fondevila (printed name),
have read, understand, and accept the terms and conditions of this Electronic Signature
Agreement. I certify under penalty of law that I have personally examined and am familiar with
the information submitted in this application and all attachments and that, based on my inquiry
of those persons immediately responsible for obtaining the information contained in the
application, I believe that the information is true, accurate and complete. I am aware that there
are significant penalties for submitting false information, including the possibility of fine and
imprisonment.
Responsible Official Signature
Plant Manager
Title
L f 5/ 74,Z2
Date
eDMR 5ubmitter Change Request Form
Page 5

E. Submitter Signature
- ; Provide a separate page of Part E for each Submtter User listed in Part B.
The Submitter (electronic signature applicant) is a user other than the Responsible Official who
submits this agreement to request to sign reports electronically. The Submitter is given
signatory authority by an individual identified as the Responsible Official by the
Owner/Organization to sign reports and other information and to accept electronic documents.
Kasey Wattley
(printed name), am authorized by the
Responsible Official named in this document, who has the authority under the applicable
standards, to enter into this agreement for Robert Bosch Tool Corporation (Owner/
Organization Name).
By submitting this application, 1, Kasey Wattley
(printed name),
have read, understand, and accept the terms and conditions of this Electronic Signature
Agreement. I certify under penalty of law that I have personally examined and am familiar with
the information submitted in this application and all attachments and that, based on my inquiry
of those persons immediately responsible for obtaining the information contained in the
application, I believe that the information is true, accurate and complete. 1 am aware that there
are significant penalties for submitting false information, including the possibility of fine and
imprisonment.
Submitter Signature
HSE Professional
Title
1 i /2 0 zz
Date
Submit_ the completed Stormwater eDMR Submitter Change Request Form in hard copy
with original signatures to:
❑EMLR Stormwater Program eDMR
Attn. Stormwater eDMR Administrator
1612 Mail Service Center
Raleigh, NC 27699-1612
eRMR Submitter Change Request Form
Page 6