NCS000222_SW Permit DOSA_20230425

ROY COOPER
Covemor
This form shall be used to delegate signature authority from the permit Owner (Permittee) to
2nother 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 comileted and submitted to the DEMLR Storniwater Pr(r,ram. Please-nole that de
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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:
a 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,
® Fora partnership or sole proprietorship, the Responsible Official shall beageneral partner orthe
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 For with original wet signatures to: NCDEMRStormwater
Program, 1612 MSC, Raleigh, NC 27699-1612
ig DT- North Carolina Department of Environniental Quality I Division of Energy, Mineral and Land Resources
512 North SallsWry Street 1 1612 Mail Service Center I Raleigh, North Carolina 27699-1612
919,70T9200

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Attach additional pages ifyou need more space.
Stormwater Permit Delegation of Signatory Authority Form
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individual with the authority to sign and submit reports for the organization.
As the Responsible Official, 1, t_S -k (printed name),
have the authority to enter into this Agreement for
—Ca �' Ifi,6e (Owner/Organization Name).
GFUNIL MWIM "I I -
form signatory authority for the above -named permit.
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By submitting this application, 1, e V (printed name), have read,
understand, and acceDt the terms ani, conditi S f, kA I
ff
Resp i Offi ial Signature
23
Title Date
Stormwater Permit Delegation of Signatory Authority Form
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