NCG050213_SW Permit DOSA_20230518

141
ROY COOPER
Governor
ELIZABETH S.BISER {�
Secretary nag
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.
armit 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
_Oliver Rubber Co. LLC
Responsible Official Name:
Nermin Hairlahovic
Responsible Official Title:
Plant Manager
Email Address;: '.`.:'.,;::` ; Phone
[e-mail]
336-636-7104
Mailing Address.:::, .:: ::
408 Telephone Ave
City. ... •..` ' .:.:: State. Zip
Asheboro NC 27205
North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
• S12 North Salisbury Street 11612 Mail Service Center I Raleigh,North Carolina 27699-1612
M1nw+..+e)a�t;+rmnmmwawinr 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 Nermin Hairlahavic
Delegated Party Title r: :. Plant Manager
Permit Number(s) NCG 050213
Email Address:. [e-mail] Phone [phone]
MailingAddress.:.:: ;: 408 Telephone Ave
City. r, ..`.: Asheboro State NC Zip code 27205
Signature of Delegated Party
indicating acceptance of.
Signatory.A.uthority: :;.
: : :,:.": May 17, 2023
Delegated Party Name; ;:..:::.:::
Delegated PartyTitle ::
Permit
Email Address:.,: Phone
MailingAddress
State Zip code
Signature of Delegated:Party
indicating acceptance of
SignatoryAuthority::: °:.`:,`: :'.:':
Delegated Party Name::... :::.:
Delegated Party.Title
•PerinitNumber(s)
Email Address:.; Phone
Mail in g 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, Nermin Hairlahovic _ (printed name),
have the authority to enter into this Agreement for
Michelin North American, Inc. /Oliver RUbber Co. LLC
(Owner/Organization Name).
•
I request that the DE MLR 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, Nermin Hairlahovic (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
110/LLU(�
Responsible Official Signature
Plant Manager May 17, 2023
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

•
DELEGATION OF AUTHORITY
The undersigned, Peter Dunphy, President of Oliver Rubber Company, LLC, a Delaware limited
liability company(the "Company"),pursuant to authority vested in him by resolutions adopted by
the Board of Managers of the Company, all as appears in the records of the Company, hereby
delegates the following authority to the following named individual who has been duly appointed
to the position stated:
Execution of any and all environmental permits which may be necessary or appropriate
for the operation of the Company's Asheboro,North Carolina facility in the normal course
of business.
Name Title
Nermin Hairlahovic Plant Manager of the Company's
Asheboro,North Carolina facility
This Delegation of Authority shall be effective from May 1, 2023 through April 30, 2024.
This Delegation of Authority shall confirm and ratify any actions taken from the effective date
listed above by the individual named herein.
This Delegation supersedes and replaces all prior delegations regarding the subject matter and the
individual named herein, and all such prior delegations are hereby revoked.
This Delegation shall automatically be revoked in the event the named individual resigns or is
terminated from the named position.
OLIVER RUBBER COMPANY, LLC
By: P.G.Dunphy(Apr 0,2 316:35 EDT)
•J Peter Dunphy
President