NCG110150_SW Permit DOSA_20230427

1-4 f NC Department of Environmental Qualify
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.
Perrnittee: Wallace Regional Wastewater Treatment Plant
Permit Number: NCG110150
Responsible Official Title: Town Manager
Email Address: [e-mail] Phone: [phone]
Mailing Address: 316 E. Murray St
City Wallace State:; NC Zip: 28466
EI
Stormwater Delegation of Signature Authority Form
Page 1
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A. Persons to Receive Signatory Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Lisa Cottle
`Delegate d Party Title: r^wwrP ORC
p.416 #Bd.P 1ty:; rganiz tion: :;:i.' Town of Wallace
:°[e-mail] Phone ::_.910-665-2091
Mailing Address; 316 E.Murray St.
City Wallace State: NC Zip;; 28466
Signature.of Delegateid.Pai +indicating:
acceptance`of Signatory Authority
Date ....::k:..
Delegated!Party;Name: Brent Dean
Delegated PartyTitle: Public Services Director
Delesgated Party Organization: Town of Wallace
1.Email Address: [e-mail] Phone [phone]
Malting Address 316 E.Murray St
City. Wallace State: nv Zip: ; 28466
Signature of Delegated Party indicating
acceptance of SignatoryAuthority.
Del g ted:Party Name: = ':' Inyoung Seo
WWTP Back-up ORC
Dole ed Pa t�i:Organization i ?`:' Town of Wallace
[e-mail] ;;.Pt101a ::.;>910-285 5927
316 E.Murray St.
Wallace tate ;.°NC Zip 28466
Signature.of:Delegated:Party Indicating
acceptance iof;Signatory Authority: �m/(/Vi 11 • C'�>
Dele:ateidP; :` ;Tite::` ` ' 'W
elegated:Party;Orgat ization``';``>s'
Email Address Phone:;:.
Signature of Delegated:Party indicating
acceptance of Signatory authority:,,:
Date:
Stormwater Permit Delegation of Signatory Authority Form
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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, Robert Taylor (printed name),
have the authority to enter into this Agreement for
Town of Wallace/ Wallace Regional WWTP (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, Robert Taylor (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Offici
Respo lsn b elel fficial Sig r
Town Manager 4-17-23
Title Date
Ic. ('erYIDOt e-ROV0-4- MWS-fl✓1 CiS 11,e i'la 101 ei
N/o CA \iict k ace �h 'I.onccJ -1 I a top ckd cI
2- ,10u,,1 Sec ,
Stormwater Permit Delegation of Signatory Authority Form
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