NCG030466_SW Permit DOSA_20230419

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ROY COOPER k .
Governor
ELIZABETH S.BISER �
Secretary +! #
DOUGLAS R.ANSEL NORTH CAROLINA
tnterLn Director EnWronntental 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 1 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 snail the DDSA Form with original wet signatures to: NCDEMLR Stormwater
Prograin, 1612 MSC,Raleigh, NC 27699-1612 j
Name of Organizational Entity
Responsible Official Name
Responsible Official Title:
�Miti� Vt.a. G
Email.Address:. Phone
roams �ry CA v, .Lt VV'% q7g
Mailing Address. 2 1 d Z Woo a
City: �fh Statc N C Zip code
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North Carolina Department or Environmental Quality I Division of Energy,Mineral and Land Resources '
2� 5I2 North Salisbury street 11612 Mall Service Center Ralelgh,North Carolina 27690-1612
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919.707.9200

A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates their acceptance of signatotyauthority.
Attach additional pages if you need more space.
Delegated Party Name ay. R-9 a,-do
Delegated Party Title
PermitNumber(s) NC- 430 b b
Email Address: Phone
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21tpc�, oSt't j
MailingAddress zz � t�do aC�
City �t� h State C Zip code Z
Signature of Delegated Party p Q
Indicating acceptance of
Signatory Authority:
Date 1[A! r1
Delegated Party Name
Delegated Party Title
Permit Numbers)
.Email Address: Phone
MailingAddress
city Statc Zip code
Signature of Delegated Pauly
indicating acceptance of.
Signatory Authority-
Date.. _.
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Delegated Party Name
Delegated Party Title ;
PermitNumber(s) .
Email Address: . Phone,
MailingAddress
city State Zip code
Signature.of Delegated Party
indicating acceptance of `.
Signatory Authority:
Date ... .; j
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Stormwater Pet,mit Delegation of SignatoiyAutliot•ityForm
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B. Responsible Official Signature
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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, -Obn� Vsl (Zv Nam - (printed name),
have the authority to enter into this Agreement for
EA-To t� (Owner/Organization Name).
I request that the DEMLR Stormwater Program include the persons listed in Part A of this
form signatoryauthorityfor the above-namedpermit.
I acknowledge that 1,and the persons Iisted in Part A of this form work at/for my
organization and have authorityto act as a signatory for purposes of the NCDEQ's
electronic document systems.
�e� W
By submitting this application,I, _ _ printed name),have read,
understand,and accept the terms and conditions of the stormwaterpermit(s)for which I
am the Responsible Official
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Responsible Official Signature
PC AA �
Title Date
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Stormwater Permit Delegation of Signatory Authority Form
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