NCG080997_SW Permit DOSA_20221118

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NOMTH CAROLINA
Eavlronmenral Quolrty
Stormwater Permit Delegation of Signature Authority Form
Directions are in red
7* This form shalt 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 may be an individual
or an organization such as a company orgovernment 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.
e 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 Name: City of Wilson Operation Center
Responsible Official Name: Grant Goings
Responsible Official Title: City Manager
Email Address: [e-mail] Phone: [phone]
Mailing Address: PO BOX 10
City Wilson state: INC I Zlp: 27894
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 dame:
Bill Bass
Delegated Party Title:
Director of Public Works
Permit Number:
NCGO80997
Email Address:
[e-mail]
I Phone:
252-399-2467
Mailing Address:
PO Box 10
Gity:
Wilson
Skate: NC
I Zip:
127894
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
o Z
Delegated Party Name:
Samuel Hed epeth
Delegated Party Title:
Assistant Director of Public Works
Permit Number
NCG080997
Email Address:
[e-mail]
I Phone:
252-399-2425
Mailing Address:
PO Box 10
City:
Wilson I
State:
INC
I Zip
27894
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
eJ. o ex
Delegated Party Name:
Noah Parsons
Delegated Party Title:
Water Infrastructure Manager
Permit Number:
NCG080997
Email Address:
[e-mail]
I Phone:
252-296-3305
Mailing Address:
PO Box 10
City:
Wilson 117
1 State:
INC
I Zip
27894
Signature of Delegated Party indicating
acceptance of Signatory Authority:
1 I U
Date:
Delegated Party Name:
Tiffenie Garner
Delegated Party Title:
Stormwater Compliance Specialist
Permit Number:
NCGO80997
Email Address:
[e-mail]
I Phone:
252-399-2434
Mailing Address:
PO Box 10
City:
WiISo
State:
NC I Zip:
127894
Signature of Delegated Party indicating
acceptance of Signatory Authority:
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, Grant Goings (printed name),
have the authority to enter into this Agreement for
City of Wilson Operation Center (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 permit.
acknowledge that I, and the persons listed in Part A of this form work at/for my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, Grant Goings (printed name),
have read, understand, and accept the terms and conditions of the storrnwater permit(s) for
which I am the Responsible Official.
ResponsibW Ofi"tiUbl'Signature
City Manager 1 1✓22
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3