NCG050243_SW Permit DOSA_20230808

ROY COOPER 6 411
Governs y► ,
ELIZABETH S.BISER �t .�"'� p •
Secretary e►orw++�+r
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 th(responsibility and compliance for
permit compliance.
Permit Owner:The legal entity to which/whom a permit has IN en issued and may be an individual
or an organization such as a company or government agency. lately 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 individhal who performs similar functions for
the corporation,or the manager of one or more manufacturiig,production,or operating facilities
who is authorized to make management decisions about the Facility operation.
• For a partnership or sole proprietorship,the Responsible Oficial 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 Ae �,
G'c6 •-te . e- ,
Responsible Official Name
nil
----FrUbl IV1 Q_____
Responsible Official Title: 3~��. di 1rj i re�. ,�
Email Address: -' Phone � 3- . 861 3 5 9
mft..for C o n,P re ,56n..c l„
Mailing Address (li t o /"0 S‹- f C.�' Gy l rh ki c z72s 3
City Gra,ka, State L Zip code 1Z1z 3
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North Carolina Department of Environmental Qtatity I Division of Energy,Mineral and Land Resources
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S12 North Salisbury Street , 1612 Mail Service Cuter Rakigh.North Carolina 27699 1612
4...ra`i�..r•d+.\ /`� 919.70/.9200

A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates theiracceptance of signatory authority.
Attach additional pages if you need more space.
Delegated Party Name 'y`o Tr t
Delegated Party Title SOS\e --) , C P c_
Permit Number(s) ,,1 CG 0-5-1S 2' 3
Email Address: Phone 3% $(ate ds actM Ax hrc;�:,�„ C U+
Mailing Address
City gr4-3.11\ State�,.) Zip code 7
Signature of Delegated Party
indicating acceptance of
Signatory Authority: _
Date S'76/'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 Stat> 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 0 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports fI r the organization.
As the Responsible Official,I, ii\o'„A T3r-o'D �-- (printed name),
have the authority to enter into this Agreement for
P\C-I-i C V -1" 'e- '` 1 f"l C.—
) (Ow •r/Organization Name).
I request that the DEMLR Stormwater Program include t • 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 oft s form work at/for my
organization and have authority to act as a signatory for • rposes of the NCDEQ's
electronic document systems.
By submitting this application,I, 1\ 7-Sit- , - ,4nted name),have read,
understand,and accept the terms and conditions of the st i rmwater permit(s)for which I
am the Responsible Official.
Resp nsible Official Signature
„.57 -11.e__I i/3 t're(.4 v----- 7 g/2-3
Title I ate
Stormwater Permit Delegation of Signat• Authority Form
Page 3