NCG050190_SW Permit DOSA_20230510

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Governor 4
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ELIZABETH S.BISER '`�7. 'r s. 7
Secretary "'
DOUGLAS R.ANSEL NOR rl I CAROLINA
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:
• 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: NCDEMLRStormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity
Elite Comfort Solutions
Responsible Official Name
Jeff Matheney
Responsible Official Title:
Environmental Health and Safety Manager
Email Address: Phone
[e-mail] 828-267-7813 x3280
Mailing Address
1115 Farrington St.
City State Zip code
Conover NC 28613
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CaronaDepartmentEnvironmental Quality I Division Energy,Mineral and Resources
NOR 1 ,D E ;���JS, 512North North SalisburyliDep Street I I612ofEnvir Mall Service Center I Raleigh,Northof Carolina 27699-1612Land
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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 Jeff Matheney
Delegated Party Title Environmental Health and Safety Manager
Permit Number(s) NCG050190
Email Address: [e-mail] Phone [phone] x3280
Mailing Address 1115 Farrington St
City Conover State NC Zip code 28613
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date 5/10/2023
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
Mailing Address
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Sto rmw ater Permit Delegation of SignatoryAuthority 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 authority to sign and submit reports for the organization.
As the Responsible Official,I, Jeff Matheney (printed name),
have the authority to enter into this Agreement for
Elite Comfort Solutions _ (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, Jeff Matheney (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
R sponsible Official Signature
•
Environmental Health and Safety Manager 5/10/2023
Title Date
Stormwater Permit Delegation of SignatoryAuthority Form
Page 3