NCG120017_DOSA Form_20221208

DocuSign Envelope ID: ED4F4FE8-DD90-4B9E-97E1-FF27BF6B186D
Flo
RECEIVE-'
DEC o :: 2022 NC Department of Environmental Quality
DEMLR-Stonwater Pr091`9rision of Energy, Mineral and Land Resources
NORTH CAROLINA
EnW,..1•1 Qu•llry
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 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.
• 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.
Permittee:
Amanda Bader
Permit Number:
NCG120017
Responsible official Title:
Director Solid Waste Mangement Department
Email Address:
[e-mail]
Phone:
1910 438-4041
Mailing Address:
698 Ann St
City:
Fayetteville
I State:
NC
ZiP
28301
Stormwater Delegation of Signature Authority Form
Page 1

DocuSign Envelope ID: ED4F4FE8-DD90-4B9E-97E1-FF27BF6B186D
A. Persons to Receive Signatory Authority
The signatures of the persons listed below indicates their, acceptance of- signatory authority.
Delegated Party Name:
Neal Cunnington
Delegated Party Title:
Environmental Compliance Manager
Delegated Party Organization:
Cumberland County -
Email Address:
[e-mail]
Phone:
1910 438-4041
Mailing Address:
698 Ann St
City:
Fa etteviIle
I State:
INC
I Zip:
128301
Signature of Delegated Party indicating
acceptance of Signatory Authority:
pus nW by:
Lv1, . biilo
Date:
-..;..BOAA5C443 12 /1/ 2 02 2
Delegated Party Name:
Tim Middleton
Delegated. Party Title:
Solid Waste Supervisor
Delegated Party Organization:
Cumberland County
Email Address:
[e-mail]
I Phone:
910 438-4041
Mailing Address:
698 Ann St
City:
Fayetteville
I State:
NC
I Zip:
128301
Signature of Delegated Party Indicating
acceptance of Signatory Authority:
D-Uftnedby:
Date. I
AA3C95037C&MF9_
Delegated Party Name:
Lou Krasuski
Delegated Party Title:
staff Engineer
Delegated Party Organization:
Smith Gardner Inc.
Email Address:
[e-mail]
I Phone:
919 828-0577
Mailing Address:
14 N Boylan Ave
City:
Raleigh
I State:
NC
I Zip:
27603
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Dwustned by:
Date: - - - -- - - - --
.FFMMMMDE -
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party Indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of Signatory Authority Form
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DocuSign Envelope ID: ED4F4FE8-DD90-489E-97E1-FF27BF6B186D
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, Amanda Bader
have the authority to enter into this Agreement for
Cumberland County (Owner/Organization Name).
(printed 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 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, Amanda Bader (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
by:
I Signature
Solid Waste Director
12/1/2022
Title Date
Stormwater Permit Delegation of Signatory Authority Form
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