NCG050340_SW Permit DOSA_20230710

•
ROY COOPER �:; `I.--.4,':
Governor
Fite fi
ELIZABETH S.BISER ` ?r ';./
Secretary
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: NCDEMLRStormwater
Program, 1612 MSC,Raleigh,NC 27699-1612
Name of Organizational Entity
�ll4,0 F4o.se. t LL C
Responsible Official Name
3.e.cewtn r1�
Responsible Official Title: i�C e S t to�� CEO
Email Address: ii c�G( r Phone
900
Mailing Address J C
/110 l001-k Mre
State ' ,{ Zip code
City
lVlitvli�llvt� tk" ��S�
J
North Carolina Department of Environmental Quality I Division of D Energy,Mineral and Land Resources E � 512NorthSalisburyStreet I.1612MailServiceCenter I Raleigh,North Carolina276 9 9-1612
919.707.9200

B. Responsible Official Signature
The Responsible Official,as identified in accordance with 40 CFR 122.22,is the appropriate
individual with the authorityto sign and submit reports for the organization.
As the Responsible Official,I, 3 02CR VY? Pdi (printed name),
have the authorityto enter into this Agree�t for
,jJldi thse COirApagj Lt.G (Owner/Organization Name).
I requestthat 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 authorityto act as a signatory for purposes of the NCDEQ's
electronic document systems.
By submitting this application,I,-S'er-e PuJ- (printed name),have read,
understand,and accept the terms and conch ns of the stormwater permit(s)for which I
am the Responsible Official.
See„,
Responsible Official Signature
Presrdeuf CEO *?/,/ 23
Title Date
Stormwater Permit Delegation of SignatoryAuthority Form
Page 3