NCG060358_DOSA Form_20230417

ROY COOPER
Governor
ELIZABETH S. BISER
se�eerYy .
DOUGLAS IL ANSEL
Inwi a afne+ Wr
N061aOUNA
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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
Win is completed and submitted to the DEMLR Stormwater Program, pj,use 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:
• 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
a For a municipality, State, Federal, or other public agency, the Responsible Offlctal shall be either a
principal executive officer [City/County Manager] or ranking elected ofilcial [Mayor].
Please mail the DOSA Dorm with original wet signatures to: NCDEMLR Stormwater
Program61612 MSC, Raleigh, NC 27699-1612
Name of Organizational Entity
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Responsible Official Name
Responsible Official Title:
Email Address:
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Phone
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MailingAddress
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State
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North Carolina Department of Envlronma ud Quality I Division of Energy, Mimal and Land Resources
512 North Salisbury Street 1 1612 Ma11 service Garter I Raleigh, North Carolina 27699-1612
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
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Delegated Party Title
Permit Numbers)
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Email Address:
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Phone
Mailing Address
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City
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State NC Zip code ,j-ro o "7
Signature of Delegated Party
Indicating acceptance of
Signatory Authority:
Date
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Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address:
Phone
MallingAddress
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
Mailing Address
Ctsv
I State
Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Stormwater Permit Delegation of Signatory Authorlty 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 authorityto sign and submit reports for the organization.
As the Responsible Official, I, [- i'1'r9 ' : (printed name),
have the authority to enter into this Agreement for
� /.aj& 1,.1 C. (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
organizationand have authorityto act as a signatoryfor purposes of the NCDEgs
electronic document systems.
By submitting this application, I, 14,UIVI. i (printed name), have read,
understand, and accept the terms and conditions o the stormwaterpermit(s) for which I
am the Responsible Official.
Res nsible Offici ig�rature
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III 7193
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3