NCS000390_SW Permit DOSA_20221006

A
NC Department of Environmental` Quality
3
Division of Energy, Mineral and land Resources
NaRTPA CARO' INA 9'Y
En Vfr"Me"ral Qu 0117y
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 parry. 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 Ovrner is the legal entity to whichlwhoin 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 qg CFR 122,22, summarized
belay
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 v.1ho 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 [CilylCouaty 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: Heritage Crystal Clean, LLC
Responsible Official Name: Anita Decina
Responsible Official Title: Vice President, Operational, Safety & Environmental Excellence
Email Address: anita.decina@mstal•clean.com Phone: 847_783-5924
Mailing Address: 12000 Center Drive, Suite East C300
City: !Hoffman Estates State: I L zip: 1160192
Stormwater Delegation of Signature Authority Farm
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A. Persons to Receive Signatory Authority
=? The signatures of Ilse persons listed below indicates therr acceptanre of signaloryauthority.
Delegated Party Name.- 'Rebekah Schulenberg
_Delegated Party Title: Environmental Manager
Permit Number: INCS000390
Email Address: Phone:
Mailing Address: �2000 Center Drive, Suite East C300
City. :Ho anstates I State: ill. ZiP' 160192
Signature of Delegated Party indicating
acceptance of Signatory Authority: /
Date: 9, f 7 ., /
Delegated Party Name: 'Greg Taylor
_Delegated Party Title: Plant Manger
` Permit Number: NCS000390
Email Address: greg.taylor@crystal•clean.com I Phone: {[phone]
Mailing Address: 2115 Speedrail Ct.
City: Concord ; State: INC i Zip: 128025
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date.- 9 t6
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Mailing Address:
City:
Signature of Delegated Party indtcaling i
acceptance of Signatory Authority -
Date:
Delegated Party Name: i
Delegated Party Title:
Permit Number:
Email Address:
Mailing Address:
City:__. -
Signature of Delegated Party indicating 1
_acceptance of Signatory Authority
Date:
Phone: i
1
State- II zip:
Phone:
State: i Zip: I
Storrnwater Permit Delegation of Signatory Authority Form
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B. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CER 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, I, Anita Decina
have the authority to enter into this Agreement for
Heritage Crystal Clean, LLC
(Owner/Organization Name).
(printed name).
I request that the QEMLR Stcrmwater 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 NCDEQ's electronic document
systems.
By submitting this application, 1, Anita Decina (printed name),
have read, understand, and accept the terms and conditions of the storrnwater permit(s) for
which I am the Responsible Official.
Responsible Official Signature
Vice President, Operational, Safety & Environmental Excellence
Title Date
5tormwater Permit Delegation of Signatory Authority Form
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