NCG210028_SW Permit DOSA_20230207

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CAROUNA
&"&WuaW" Q=wY
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
=> This forrn shall be used to delegate signature authority from the permit Owner (Permitfes) to
another party. Only the Responsible Official deRned 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 whichAvhom 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 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].
=> Ever: if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
Permittee: I Baxter Healthcare
Permit Number: INCG210028
Responsible Official Title: Timothy Marini
Email Address: [e-mail] Phone: 828_756-4151
Mailing Address: 65 Pitts Station Road _
City: Marion IState: NC zp: r28752'
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.
i Delegated Party Name: [e-mail]
Delegated Party Title: Environmental Manager
Delegated Patty Organization: Baxter Healthcare Corporation
Email Address: [e-mail] I Phone: [phone]
Mailing Address: 65 Pitts Station Road
City: Marion
Signature of Delegated Party indicating Rik
acceptance of Signatory Authority:
Date:
State: I N C I ZiP: 128752
Delegated Party Name: William Carter
Delegated Party Title: EHS Manager
Delegated Party Organization: Baxter Healthcare Corporation
Email Address: [e-mail] Phone: [phone]
Mailing Address: 65 Pitts Station Road
City: Marion I State: INC I Zip: 128752
Signature of Delegated Party indicating
acceptance of Signatory Authority_
Date: 26 Sp.il Zaz
Delegated Party Name:
Delegated Party Title:
Matthew Morin
Environmental Specialist
Delegated Party Organization:
Baxter Healthcare Corporation
Email Address:
Matthew [e-mail]
Phone: [phone]
Mailing Address:
65 Pitts Station Road
City:
Marion
State: NC I
Zip:
128752
Signature of Delegated Party indicating
acceptance of Signatory Authority.
Date:
1/.,W120 22
Delegated Party Name:
Delegated Party Title:
Delegated Pa O ar ization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zipe
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, Timothy Marini (printed name),
have the authority to enter into this Agreement for
Baxter Healthcare Corporation (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 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, Timothy Marini (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Site Director
Title
Signature
e,1; , , " Zo-11
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3