NCG060014_DOSA Form_20220822

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NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORtH. CAROLINA
EnWrorunenlal QaaRry
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 maybe 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 for compliance with permit conditions.
Organization Names
Ajinomoto Health & Nutrition North America Inc
Responsible Official Name:
Andrew Steinhauer
Responsible Official Title:
General Manager
Email Address:
[e-mail]
I Phone:
919.723.2196
Mailing Address:
4020 Ajinomoto Drive
City:
Raleigh
I State:
NC
I Zip:
27610
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
=> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Ricky McFarland
Delegated Party Title:
Associate Manager EHS
Permit Number:
NCGO60000
Email Address:
[e-mail]
I Phone:
1919.455,6717
Mailing Address:
4020 A'inomoto Drive
City:
Raleigh
State:
INC
I Zip:
27610
Signature of Delegated Party indicating
of Signatory Authority:
Alacceptance
%/ C4
Date:
07/26 022
Delegated Party Name:
Marion Wearing
Delegated Party Title:
EHS Specialist
Permit Number:
NCG060000
Email Address:
[e-mail]
I Phone: [phone]
Mailing Address:
4020 A'inomoto Drive
City:
Ralei
I S te:
INC
I Zip:
127610
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
07/26/2022
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:
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

E. 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.
I, Andrew Steinhauer (printed name), have the authority to enter into
this Agreement for Ajinomoto Health & Nutrition North America, Inc. (Owner/Organization
Name).
I request the NCDEQ grant me and, if included in Part B of this form, the named User(s), an
electronic signature credential to submit and accept documents electronically on behalf of my
organization.
I acknowledge that I, and if included in Part B of this form, the named User(s), work at/for 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, I, Andrew Steinhauer (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.
General Manager
/ X e-D 8' 7 Zv2Z
Responsib a Official Signature Title Date
eDMR User ID
Stormwater Electronic Reporting Registration Form
Page 6