NCG120058_SW Permit DOSA_20230207

DOUGLAS R. ANSEL NORTH CAROLINA,
fnl&ih» oirocw Environmental Qaaflty
.Stormwater Delegation of Signature Authority Form OSA
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 bythe permit (such as Data Monitoring Reports and Annual' Reports) until this
p grain; Please note that delegating
form is com l:eted and submitted to.the'I7EMLR 5tormwater Pro
sigLiature authority. does not relieve the Permit. Owner from the responsilift and compliance for
permit compliance.
Permit Owner; The legal entity to which/whom a permit has been issued and may bean 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 fiinctions for
tile, corporation, or the manager of one ormore manufacturing, production, or operating facilities
who is authorized. to make management decisions about the fa. cilky 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 o rigii al wet signatures to NCDEMLRStormwater
Program, 1612 MSC; Raleigh, NC 27699-1612

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.
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Stormwater Permit Delegation of Signatory Authority Form
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B. Responsible Official Signature
The Responsible Official, as identified in accordancewith 40 CFR 122.22, is the appropriate
individual with the authorityto sign and submit reports for the organization.
�) r
As the Responsible OfFicia , I, Y�'� �� (printed name),
have the autl rity� ent#r into thifi Agreement for
(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, 4 S Sf J \ (printed name), have read,
understand, and accept the terms and conditions ofthe stormwaterpermit(s) for which I
am the Responsible Official.
PA ,y` G t
Title
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Date
Stormwater Permit Delegation of Signatory Authority Form
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