NCG030694_SW Permit DOSA_20221117

NC Department of Environrnenral Ouality
Division of Energy. Mineral and Land Resources
NO9T14 CAM OIIt, A
Eftioa wrwrdQrsay
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 rosponsibility for permit
compliance.
The pear:.,( 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 dry CFR 122 22, summarized
below:
r For a corporation, the Responsible Official shall be a president. Secretary, treasure►, or vice-
president on 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 OfliciaJ shall be a general partner or the
proprietor, respectively; or
For a municipality, State. Federal, or other public agency, the Responsible Official shall be ether a
principal executive officer [GirylCounty Manager] or ranking elected official [Mayorl_
Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions
Organization Name: Oracle Flexible Packaging. Inc. (Former) Cunningham Plant
Responsible Official Name' Danny Leonard
Responsible Official Title: Plant Manager
Email Address. dleonardQa llflex,com 1 Phone: [phone]
Mailing Address: 738 Gallimore Dairy Road
COY High Point State:: ]NC [*.]27265
Stormwater Delegation of Signature Autt*nty Form
Page 1

A. Persons to Receive Signatory Authority
The signahires Of the persons listed below indicates the+r acceptance of signatory authority.
Delegated Party Name_: Tiffany Tuiea
Delegated Party Title: HR s Safety Representative
Permit Number. NCGO30694
Email Address: ttuleckaaex cam Phone: [phone]"
Mailing Address: 738 Gmjl more Dairy Road
City' rugrLPgr,t State: sic ? Tip: �zrzss
Signature of DeMgMed Party indicating
acceptance of SOWM Auttionty
Date:
11115 I ?
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address- PFrone:
Mailing_ Address:_
City: State: Zip:
Signature or Delegated Party indicating
ivtaptance of Signatory Anti onty.
date:
Delegated Party Name
Delegated Party Title:
Permit Number.
Emad Address: Pltane; --
Mailing Address:
City:
Signature of 17e1egated Parry indicating
aoce"nce of signatory Authorityr.
Date:
Delegated Party Name:
Delegated Parry Title;
Permit Number,
Email Address:
Mailing Address
City.
Signature of Delegated Party tnd p
acceptance of Signatory AuthoW..
Date
! Pl,an�
State: Zip:
Stormwater Permit Delegation of Signatory Authority Form
Page 2

R_ 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, DannyLeonar-d (printed name),
have the authority to enter iniv this Agreement For
LLFIex, LLB
(OwnerfOrganizatiorl Name).
request that the DEMLR StGrmwatef Program indude the persons listed in Part A of This form
Signatory aulhority for the alive -named perm it,
acMowledge that I, and the persons listed in Part A of this form work al/for my organization
and have authority to act as a signatory for purposes of the NCDEQ-s electronic document
systems.
By submitting Ihis application, I, Danny Le vrd (printed name),
have read, understand. and accept the terms .and conditions of the stormwater permits) for
which I am the Responsible Official.
R4pQnsible dfficial Signature
Mani Olreciar f
Title Dale
Slorrowaler Permit Del&gatiam of $i�r, story Authority Form
Page a