NCG080716_DOSA Form_20230417

ROY COOPER
Governor
ELIZABETH S.BISER "<• 1013
Secretary
DOUGLAS R.ANSEL NORTH CAROLINA wae�p�o9tam
Interim Director 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
• Fora municipality,State,Federal,or other public agency,the Responsible Official shall be either
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 Pilot Travel Centers,LLC
Responsible Official Name
Joey Cupp
Responsible Official Title:
Director,Environmental
Email Address: Phone
[e-mail] 865-474-2826
MailingAddress
5508 Lonas Drive
City State Zip code
Knoxville TN 37909
North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
512 North Salisbury Street 11612 Mail Service Center I Raleigh,North Carolina 27699-1612
Win,rw-+aw
c..�:�....+u.n 919.707.9200

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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 Robert Wagner
Delegated Party Title Sr. Program Manager
PermitNumber(s) NCG080716 NCGO80143 NCGO80134 NCG080428 NCGO80170
Email Address: PPhone
rwa ner@crawfordenvironmental.c m 540-343-6256
MailingAddress: 1701 Shenandoah Ave NW
City Roanoke State Vp Zip code 24017
Signature.of Delegated Party
indicating acceptance of
• Signatory Authority:
Date 4/7/23
Delegated Party Name
Delegated Party"',Title
Permit Number(s)
Email Address: Phone
Mailing Address
City State Zip code
Signature of Delegated Party
indicating acceptance of
SiggatoryAuthori_ty:
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Addres§:7-- Phone
f
MailingAddress
• City State I 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 authorityto sign and submit reports for the organization.
As the Responsible Official,1, Joey Cupp (printed name),
have the authorityto enter into this Agreement for
Pilot Travel Centers,LLC _ _ (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 authorityto act as a signatoryfor purposes of the NCDEQ's
electronic document systems.
By submitting this application,1, Joey Cupp (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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Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3