NCS000107_SW Permit DOSA_20221011

At •
iF NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CAROLINA
LW/vim/wire Quality
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
-> 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 for permit
compliance.
-> The permit Owner is the legal entity to which/whom a permit has been issued, and maybe 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].
-> Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
;_organization Name: Hallstar Industrial Solutions Company
Responsible Official Name: Dan Fitzgerald
Responsible Official Title: Vice President
Email Address: [e-mail] Phone: [phone]
Mailing Address: 120 S. Riverside Plaza; Suite 1620
City Chicago -- I State: IL Zip: 60606
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
The signatures of the persons listed below 6ldcafes their acceptance of signatory authority.
I
Delegated Parry Name: TattyTattyHUM _
Delegated Party Title: - Plant Manager
1 Permit Number _ NCS000107
I Email Address: thurst®haltstar.com _I P 1338-378-0965 -
Mailing Address: 520 Broome Rd
City: Greensboro _• State:, C ZP:127406 /
Signature el Delegated Party Indicating
scctptana of Signatory Authority:
Date: -- - -Q - - Q1 - - —
FD-elegated &Ye Party Name: ;FrarxheBrewer _
Delegated Party Title: rHSE Manager —
{l
Permd Number NCS000107
Email Address: Ibrewer®hallstar.com IMtert� 36. 78.0965 -
Mailing Address: 520 Broome Rd _ _ •
ray r+eonsboro stoic NC ZIP: J27406 t
Signature of Delegated Pasty J
•
inputting.
acceptance of Signatory Authority: -i
I Dale: 7 2° —1 •
r Delegated Party Name: _
Delegated Party Tdfe:
Permit Number.
Email Address: I Phone: — —
aMatlint Address: _ - -
City. I State: I ZIP:
Signature of Delegated Party Indicating
acxptanc*of 5gnatory Authority. -
Date: _ - -- - -- ^1
Delegated Party Name: - —
Delegated Party e: — - — -- —Titl
Permit Number: _
Email Address: Phone; I
Mailing Address:
City: — I State: I I Z :1
rSIgnature of Delegated Patty indicating
acceptance of Signatory Authority.
, Date:
Stormwater Permit Delegation of Signatory Authority Form
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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, Dan Fitzgerald (printed name),
have the authority to enter into this Agreement for
Halistar Industrial Solutions Company (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, Dan Fitzgerald (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s)for
which I am the Responsible Official.
Responsible Offici ignature
Vice President i0/4/2022
Title Date
Stormwater Permit Delegation of Signatory Authority Form
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