NCG030208_SW Permit DOSA_20230420

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
DOUGLAS R. ANSEL
Interim Director
NORTH CAROLINA
Environmental Quality
Stormwater Delegation of Signature Ail<tliority Form (DOSA)
This form shall be used to delegate signature authority from the permit Owner (Pertnittee) 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 Ito the DEMLR Stormwater Program. Please note that deleg i ig
§igna_ture authority does not relieve the Permit Owner from the
resp-Qnsibility and compliance for
permit conipliance.
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
• 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: NCDEMLR Stormwater
Program, 1612 MSC, Raleigh, NC 27699-1612
Name of Organizational Entity
McGee Co rP-qr�o�
Responsible Official Name To dtJ C (le e�
Responsible Official Title:
Pres ]den-r,
Email Address: Phone
Dodd , McClt:� me K o, .cDrn gog - aga
MailingAddress a 00 5;JMI 1tr1G
City MQ { �'1ell�s State N � Zip code r1 g
�w_ North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
z!rw:0-fD1E •�/j� 512 North Salisbury Street 1 1612 Mall Service Center 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
I 5 I KC.S
Delegated Party Title
H R E Sa f6
Permit Number(s)
NCCg 03 ) Q
u I ie S M Cg[,pr Phone 17oq-gq3 %dI
Email Address:
Mailing Address
rJ
city
+ji, W-S
State
I tj
Zip code
O I () Lp _ I
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
'
! J h
LLJ�-�•
Date
r7S
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
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
Paize 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, I, —1—oU d AA C 6 C C- (printed narne),
have the authority to enter into this Agreement for
(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
organization and have authority to act as a signatory for purposes of the NCDEQ's
electronic document systems.
By submitting this application, I, _OdJ K (printed name), have read,
understand, and accept the terms and conditions of the stormwater permit(s) for which I
am the Responsible Official.
r'� - __V k
Responsible Official Signature
Presiden
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Paae 3