NCG030655_SW Permit DOSA_20230313

ROY COOPER
Governor
ELIZABETH S. B1SER
Secretary
DOUGLAS R. ANSEL
Interim director
NORTH CAROLINA
Environmental Quality
Stormwater Delegation of Signature Authority Form (DOSA)
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. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility and compliance 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:
Fora 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].
Please mail the DOSA Form with original wet signatures to: NCDEMLRStormwater
Program, 1612 MSC, Raleigh, NC 27699-1612
Name of Organizational Entity
American Roller Bearing Inc. - Hiddenite
Responsible Official Name
Edward L. Goodin
Responsible Official Title:
Plant Manager
Email Address:
Phone
[e-mail]
1704-585-2908
MailingAddress
PO Box 1 1 7
City
State
Zip code
Hiddenite
INC
128636
P
North Carolina Department of Environmental Quality I Division of Energy. Mineral and Land Resources
�/512 North Salisbury Street 1 1612 Mail Service Center I Raleigh, North Carolina 27699-1612
IEQ,
N.
— 919.707,9200

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
Richard Murdock
Delegated Party Title
Facilities Manager
Permit Number(s)
NCG030655
Email Address:
[e-mail]
I Phone
704-585-2908
MailingAddress
PO Box 117
City
Hiddenite
State
INC
I Zip code
128636
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address:
Phone
MailingAddress
City
State
Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address:
Phone
MailingAddress
City
State
Zip code
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,1, Edward L. Goodin _
have the authority to enter into this Agreement for
(printed name),
American Roller Bearing Inc - Hiddenite __—_ (Owner/Organization Name).
I requestthat the DEMLR Stormwater Program include the persons listed in Part A of this
form signatory authority for the above -named permit.
I acknowledge that 1, and the persons listed in Part A of this form work at/for my
organization and have authority to act as a signatoryfor purposes of the NCDEQ's
electronic document systems.
By submittingthis application,1, Edward L_Goodin _ ^ (printed name), have read,
understand, and accept the terms and conditions of the stormwater permit(s) for which 1
am the Responsible Official.
Z.M' _e�_ _J1 I— �k -
Responsible Official Signature
Plant Manager
Title
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3