NCG190090_SW Permit DOSA_20221219

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A. Persons to Receive Signatory Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
-
Delegated Party Name:
James D. Frei
Delegated Party Title:.
Consultant
Permit Number:
NCG190090
[e-mail] L.Phone:- 919-661-9954
8916 Oregon Inlet Ct
Raleigh State: NC ZP: 27fiO3
Email Address:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
.fired bt.esn Fm
James D. Frei otlm,.FI�.iPy«m,9iv, aN5
Date:
12/1912022
Delegated Parry Name:
Delegated Party Title:
Permit Number; -
Email Address.
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority.
Date:
Phone_- 1 {) £ (,6 4LI
State: !C Zip:
Delegated Party Name:
Delegated Party Title:
Permit Number:
NGG190090 '
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
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, DCL;0 1 L{ nl�1 (printed name),
have the authority to enter into this Agreement for
" I i k_e, L LC (Owner/Organization Name).
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, I, 1.�c Via JtLW—(t hQ (printed name),
have read, understand, and accept the terms and conditions o he stormwater permit(s) for
which I am the Responsible Official.
Responsible Official Signature
l 2 11
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3