NCG070226_SW Permit DOSA_20230505

go STATE n
ROY COOPER g .a r f.
Governor , ;*_1 Z ;.
ELIZABETH S.BISER . ^ ,Ln /''
Secretory Q°r'"M
DOUGLAS R.ANSEL NORTH 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: NCDEMLR Stormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity Potters Industries LLC
Responsible Official Name Don Blackhurst
Responsible Official Title: Vice President-Operations
Email Address: Phone
[e-mail] 610.764.3250
Mailing Address 3222 Phoenixville Pike,Suite 103
City Malvern State pp Zip code 19355
D E Q,,#) North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
512 North Salisbury Street i 1612 Mail Service Center I Raleigh,North Carolina 27699-1612
oa,,,,,,,,,,L,;,.'”,..p.m, 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 William Tornow
Delegated Party Title Plant Manager- Thomasville, NC
Permit Number(s) NCG070226
Email Address: [e-mail] Phone [phone]
Mailing Address 1202 East Sunrise Ave
City Thomas e State NC Zip code 27360
Signature of Delegated Party
indicating acceptance of 1/1,
Signatory Authority:
Date l c/zO Z 3
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
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 authority to sign and submit reports for the organization.
As the Responsible Official, I, Don Blackhurst (printed name),
have the authority to enter into this Agreement for
Potters Industries LLC (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, Don Blackhurst (printed name),have read,
understand, and accept the terms and conditions of the stormwater permit(s) for which I
am the Responsible Official.
Responsible Official Signature
Vice President- Operations
Title Date
Stormwater Permit Delegation of Signatory Authority Form Page
3