NCG190033_SW Permit DOSA_20230203

ROY COOPER
intFf"M Dtrr.o'or
NOR FH CAR'X €rig
FnVII-Orxrrtenteaf Qualify
Storm'vvater _delegation o ' Si n.Gi .,iii e ALIthOrity OI 111 - OS.d
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. Ple.s to that delegating
signature gUlbprily.dogs not relieve the Permit Owne om the resl2onsibili1y aLld CDMpliance for
permit compliance.
Permit Owner: 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 managerof 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].
Please mail the DOSA Form with original wet signatures to: NCDBMLRStormwatear
Program, 1612 MSC, Raleigh, NC 27699-1612
Name of Organizational Entity
Conscience Bay T LC dUa Town Greek Marina
Responsible Official Name
,
Responsible Official Title: .
Email Address:
carolLtowncreektnarina.eo
Phone
252-728-611 l
Mailing Address
114 Town Creek Dr
City
Beaufort
State
State
Zip code
28516
" S North th U of : e Qir aljty Division of F i rqF 1'14 eC d and i xt d R c urce�
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A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Attach additional pages if you need more space.
Delegated Party Name
James D. Frei
Delegated Party Title
Consultant
Permit Nurnber(s)
NCG190033
Email Address:
jdfrei@,,stormwatergroup.com
Phone
91.9-661-9954
MailingAddress
8916 Oregon Inlet Ct
city
Raleigh
State
NC
Zip code
27603
Signature of Delegated Party
indicating acceptance of
Signatory Authority:.
Date
01 /20/2023
Delegated Party Name
Steve Tulevech
Delegated Party Title
Operations Manager
Permit Number(s)
NCG 190033
Email Address:
�t f�,
Phone
252-728-6111
MailingAddress
114 Town Creek Dr
City
Beaufort
State
NO
Zip code
28516
Signature of Delegated Parry
indicating acceptance of
Signatory Authority:
Bate
01 /2W2023
Delegated Party Name
Cav-b1 'TG Lp- ve
Relegated Party Title
` tDr� KAo YA
Permit Nuinber(s)
NCG 190033
Email Address:
vx� nl-. c. \
Phone
MailingAddress
�'..
City
State
Zip code
1
Signature of Delegated Party
indicating acceptance of
Signatory Authority:-�
Date/
3
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, �I V_51_\ "- 7U (,f-V-e(printed name),
have the authority to enter into this Agreement for
Conscience Bay LLC dba Town Creek Marina (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 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, S4-1r�"- (printed name), have read,
understand, and accept the terms and conditions of the stormwater permit(s) for which I
am. the Responsible Official.
Responsible Official Signature
Title
01 /2012023
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3