NCG170377_SW Permit DOSA_20220815

r-; NC Departwentof EnvirofJ101401011814
Division of Energy, Mineral and Land Resources
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Stormwater Permit Delegation of Signature Authority Form
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This form shall be used to delegate signature atlthurlty 11001 file pornlit Ownef (t'eriniltee) to
another party. Only the Responsible Official defined helow miry slrbmil purinil applications and
reports required by the permit (such As Data Monitoring Reports and Annual Ropolts) until this
fornl is corllpletod and submitted la tiro DEMLFr Stornrwatar Program. Please note fhaf dolugafinrl
signaluro Authority does not foliove the Perrnit Owner fron! Ihti rosponsibllify fur permit
conmllanco.
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organization Name: Culp, Inc.
Responsible Official Name: Teresa Huffman
Responsible Official Title: VP of Human Resources
Email Address: tahuffman@culp,cotn
Mailing Address: 1823 Eastchester Drive
City: High Point -
! Phone_ 1336-889-5161
Stale: INC I Zip: 127265
Stormwater Delegation of Signature Authority Foml
Page 1

A. Persons to Receive Signatory Authority
Delegated Party Name:
Chad cusin
Delegated Party Title. _
E --
Plant Manager
Permit Number:
NCG 170377
Email Address:
_
Mailing Address
cetiuyrn r(�u,lf,Xk)M Phone, 1336-Ga3.7751
Po Box •
-- - --
City:
aea
9tokesclate !f State: tVCi ' Z73s,7
Signature of Detegated Party �rtpicating
acceptance of Signato Authgi
I! - -- — r - — __.--�—_L ! __----
Date:
--
Delegated Party Name-
Delegated Party Title
Permit Number,
Email Addres&:
Mailing Address;- -f
City -
Signature of Delegated Party Irn icating
acceptance of Signatory AWho6ly
Data. ` ---------+'--_- - I ----
Delegated Party Name -
Delegated Party Title_
Permit Number_
Entail Address:
Mailing Address- -
City.
Signature of Delegated Party i tin$
acceptance of Signatory Autho
Date:
D%i"ated Party Name. -
Delegated Party Title. i
Permit Number.
Email Address-9 s
i
Address -
Mailing Address
y?
City. -- f
i Signature of Delegated Party in gating
! acceptance of Signatory Authari�
Date:
Phone:
State l .. Zip _E
Phone: !
i
- - - - -- state.
Zip:
Phone:
-- -- State: Zip. I
Storrtlwater Permit Delegation of Signatory Authority Form
Page 2

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, Teresa rfUffarl8n
have the authority to enter into this Agreement for
Culp. Inc.
(Owner/Organization Name).
(printed 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 allfor my organization
and Have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, 1umsa lluthnan (printed name),
have read, understand, and accept the terms and conditions of the slormwater permit(s) for
which I am the Responsible Official.
1) WA -a, A 14 4i rncu,�
Responsible Official Signah►re
`]VP ofIturnan Rosuurces
Title
Date
Storrmvater Permit Delegation of Signatory Authority Form
Page 3