NCG080196_SW Permit DOSA_20230223

DocuSign Envelope ID: A29BE9EE-DB1 2-4932-9DF5-F4FC4FA1 4099
r NC Department of Environmental Quality
0�il
Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental Quality
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
=> 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 for permit
compliance.
The permit Owner is 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 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].
Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
Organization Name:
United Parcel Service, Inc.
Responsible Official Name:
Mario Venditti
Responsible Official Title:
Corporate Environmental Manager
Email Address:
[e-mail]
Phone:
�1-305-613-4748
Mailing Address:
6001 E. 8th Ave Attn: BaSE Corporate Environmental Manager
City:
Hialeah
State:
K
Zip:
133013
Stormwater Delegation of Signature Authority Form
Page 1

DocuSign Envelope ID: A29BE9EE-DB1 2-4932-9DF5-F4FC4FA1 4099
A. Persons to Receive Signatory Authority
=> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Mario Venditti
Delegated Party Title:
Corporate Environmental Manager
Permit Number:
NCGO80196
Email Address:
[e-mail]
Phone:
1-305-613-4748
Mailing Address:
6001 E. 8th Ave Attn: BaSE Corporate Environmental Manager
City:
H gFe&uSigned by:
State:
FL
I Zip:
33013
Signature of Delegated Party indicating
acceptance of Signatory Authority:
—
0646AJK60F4
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number:
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

DocuSign Envelope ID: A29BE9EE-DB1 2-4932-9DF5-F4FC4FA1 4099
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, Mario Venditti
have the authority to enter into this Agreement for
United Parcel Service, Inc.
(Owner/Organization Name).
(printed 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 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, Mario Venditti (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
DocuSigned by:
MARA t S(:Rn Fdd R7
Responsible Official Signature
Corporate Environmental Manager
Title
12/16/2022
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3