NCG120117_DOSA Form_20230907

NC Department of Environmental Qualfty
t{
Mineral
Division of Energy,
Stormwater Permit Delegation of Signature Authority Form
Directions r in red.
Is
another party. Only the Responsible Official defined below may submit permitt applications and
Thi form shall be used to delegate signature authonoty from the pennit Owner(Permittee) to
compliance.reports required-by the permit(such as Data Monitofing Reports and Annual Reports) until this
form I's completed and submitted to the DEMLR Stormwater Program., Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility for permit
The permit Owner is the legal entity to which1whomb it has beenissued, and mayindividual
r an organizationcompany or government agency. Every Owner is required to have
Responsible iil who meetsthe legal signature authorityrequirements in 40 CFR 122. summarized
below:
r a corporation, t s nilOfficial shall be a president, secretary, tr srr, orvice-
president in chargeri ci l business function, r another individual who performssimilar
functions for the corporation, or the manager of one or more manufacturing, production, r operating
facilities who is authorized to make management decisions about the facility operation.
r a partnershipor sole proprietorship, the Responsible Official shall be a general partner or the
proptietor, respectively;or
r a municipality, State, Federal, or other public agency, the Responsible Official shall be either
principal executive officer it l ount Manager]or ranking elected official ay®r
Even if delegatedsignatory authority has been delegated to another individual, the Responsible Official
retains responsibility for co mpliance with permit conditions.
rgahlization,NNA-me-,-i Greene County
e
XyIeDeHaven
.Res S
p"-Ib 'OffidW7,14� ... 1 -Manager
E.� d
:N ' k [e-mail]252-747-3446
r229 KingoldBlvd, Suite
7-7
gy
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I -State,
28580
Stormwater Delegation of SignatureAuthority r
Page 1

A. Persons to Receive Signatory Authority
The signatures r listed indicates their acceptance of signatoryauthority.
Works:.DeWgated. Wimee David Jones
Title,: Public
Mat'Ad r
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." ,
P.O.Box 543
y;
Snow Hill A128580
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Stormwater Permit Delegation of SignatoryAuthority r

identifiedB. Responsible Official Signature
The Responsible Official', as , is the appropriate
individual i ign and submit reports for the organization.
ResponsibleAs the i , 1, -- Haven
kprinted name),
authorityhave the into thisr
Greeneurn (Owner/Organization
I request that the DEMLR r Program include r listed in Part A of this
signatoryi .
acknowledgei, and the personslisted in Part A of thisr r my organization
authorityand have i r electronic
systems.
By submitting is a-pplication, l, (printed
have read, understand,-and accept the terms and conditions i
whichl am the Res nsm
l i ` 1.
o
Resp
I*"
i i
County Manager
Title t
Stormwater Permit Delegation of SignatoryAuthority