NCS000572_SW Permit DOSA_20221129

NC Department of Environmental Quality
��-• Division of Energy, Mineral and Land Resources
NORTH CAROLINA
EnvimiffmMl Quality
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 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 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 Name: IDuke Energy Dan River Combined Cycle Plant
Responsible Official Name: ITerry Tuck
Responsible Official Title:
Email Address:
Mailing Address:
City:
Plant Manager; General Manager II
[e-mail] I Phone:
S. Edaewood Rd
Eden,
State:
Stormwater Delegation of Signature Authority Form
Page 1
Zip: 127288

A. Persons to Receive Signatory Authority
� The signatures of the persons listed below indicates their acceptance of signatory authority
PefrtIt N~.
Signature of Datagatad Party Weaft
LDS ,
gated Party Name:
Delegated PagTitle:
Permit Number.
Emd Address: —
Malldng Address:
City:
S*mhue of Deflated party fndWVng
: tars:' of st�nator Jr autbo �r.
Date:
Delegated Pa Name:
DelWted Pnq Title:
Permit Number
Email Address' _
CRY;
i ; _
Signature of Delegated Party indicatigg
"to nce of
1 Dates -
DelegetediParty Name:
Delegated'PeAl Title:
Permit Ntimbbr.
Email Address:
i Mailing Address: _—
City:
Signatureof DolinFI d hPar
Date:
tndicaing
Be emir Johnson
Su dnte ident Maintenance
MCS0005722 _
Benjamsn.jdbrwm34duke-energy.com I Phone: 36.6
B64 S. Edgewood Rd Eden _ Tr
State: INC_ 7
1/1812022 - - -a
Metcalf --__
wIntendent O rations
1000572
ass.matralt@duk"nergymm Phone: [phone]
S. Edgewood Rd �
Steta -NC t�pJ272BB -
Brandon Guess W
Superintendent Operations
NCS0000-
bnrrxan.bisrQes� uka-snargy.wm j Phone: [phone]
40 Ernest Dr _
;Reidsville I State: NC 'I ZIP: 7320 _
--udcs�-
1/18/2022 — -
Stormwater Permit Delegation of Signatory Authority Form
Page 2

13. 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, Terry Tuck (printed name),
have the authority to enter into this Agreement for
Duke Energy Dan River CC (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.
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, Terry Tuck (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
A,
sible Official Signature
Plant Manager; Genereral Manager li
Title
11/15/2022
Date
Stormwater permit Delegation of Signatory Authority Form
Page 3