NCS000107_SW DOSA Form_20221013

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CAROUNA
&IVY /N WQN•Ylr
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
=5 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 Stormwafer 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 businoss 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-managementdecisions-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).
a Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
Organization Name:
Hallstar Industrial Solutions Company
Responsible Official Name:
Dan Fitzgerald
Responsible Ofliccial Title:
Vice President
_
Email Address:
[e-mail]
I Phone:
708-594-5050
Mailing Address:
120 S. Riverside Plaza; Suite 1620
City:
Chicago
State:
IL
ZiP:
60606
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
The signatures of the persons fisted below indicates their acceptance of signafory authority.
f-Debgeled Party Names [e-mail]
arry HutstTrite:lant Manager
I PemtitNumber. CSO00107
EmailAddress: Phone
Date: 1 1016,17 l 201- Y
Delegated Party Name: _
randtellie &serer
DetegatedPartyTdle:
HSEManagerr-
PermlNUmber
CS000107
Email Address:
Ibrewer®hallatarcom
Mailing Address: _
20 Broome Rd
city
3monstoro
I StateINC I ZIF. F406
Signsiwe orDefegatw Party kwici e4
d
acceptsme or SoutoryA lhoW.
Dale: — —
07 20
— —
Delegated Party Name:
_
_
—
Delegated PartyTft
Permit Number.
—
6i ad Address:
_ --- —
--
Phone: — —
-_-
Malinj Address:
City:
_
Slate: �`_L
Signature or Delagated Pxly Wkotna
ecxptancs of signatory Aulmr9r._
Date:
Dalagaled Pang Name:
—
DdegatedParty Title:
— -
Permit Number.
— -
Emall Address --_ - -
_-
Mailhg Address:
,_.
-_
---Phona
city,
Signature of Delegated Pally IndiaWg
t orrnplanea U Slpnabry Aralrodty:
Date:
StorMwater 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, Dan Fitzgerald (printed name),
have the authority to enter into this Agreement for
Hallstar Industrial Solutions Company (Owner/Organization Name).
I request that the DEMLR Stormwater Program include the persons listed in Part A of this form
signatory authority for the above -named pen -nit.
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, I, Dan Fitzgerald (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Responsible Oflici gnature
Vice President
Title
ia412022
Date
Stormwater Permit Delegation of Signatory Authority Form
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