NCG210249_SW Permit DOSA_20221219

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
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
farm is completed and submitted to the Df=MLR 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 CFI-,' 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_
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.
Gary Middleton
COO _
210249,210188
[e-mail] Phone .,_ 434-949-7707
P.O. Box 100
VA IGip::::: ` 23821
car. ,ueiegatI% Party indlcating,.>': fit
a�'pf 5rgnaYory AuthorEty
1211 S
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, Donald C. Bright
have the authority to enter into this Agreement for
Meherrin River Forest Products
(Owner/Organization Name).
(printed name),
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, 1, Donald _C._Bright (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
whirh I sm the RPCP nnQihIA (Wrini
President
Title
12/19/2022
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3