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The. aIgnalum of the persons fisted below indketes. their acceptance of s►ignatbry autho*.
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Stonmwater Renmit omega � S&�na#ory Authority Foam

w. mesponsibie Officiall Signature
The Respontible Official, as ide''ntified In accordarce with 40 CFR 122.22, is the appropriate
individual with the aut-hority to sign, and subrnk reports fbr the o M-Janm*atton.
thga; Respansible Official I - Erandsm nnfaQ
A -000 'eat
have the authority to enter into this Agreement for
FM Req)Om LLC (Owner/Organization Name).
I request, that.the DEMLR Storm water Program inftfude the persons listed in Part A of this fry
signatory authority- for the above -named permit,
I acknowledge that. 1,.and the persons listed in Part A of this form woo (iVf0_r__m_yo_rg_a_nI i—atio-h-
and have authon"ty to act as-. a signatory for purposes of the NCDEQs electronic docurnerit
sygteMs.
By submitting. thin application, 1, Fratncisw. Montes. (printed -name),
have- read, understand, and accept the terms and conditions of the stoftwate'r pe',nnit(s). fdr
which I am the. Respo'nsible Official.
Responsible Offidal Signsture
CEO
Title
06/15/202.2
Date
Stormwater Permit Delegafion of, Signatory Authority. Fqrm
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