NCG060336_SW Permit DOSA_20231102

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ROY COOPER , r •
Governor
ELIZABETH S.BISER
Secretory =
DOUGLAS R.ANSEL NORTH CAROLINA
interim Director Environmental Quality
Storm water 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 Stoninvater Program. Please note that delegating
signature authority sloes 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 he 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 authotity requirements in 40 CFR 122.22,
summarized below:
• Fora 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.
• Fora partnership or sole proprietorship,the Responsible Official shall bea general partner or the
proprietor,respectively;or
• Fora municipality,State,Federal,or other public agency,the Responsible Official shall he 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
Pres4-Q3e, firms Cgs rn;l/)
Responsible Official Name /� �+ re.
Official Title: {? , &h.
Email Address: // L �' Phone /' r �1
\Jahn,C yr-e.AJC arWk ,co/41 `ia'492�J //
Mailing Address �O Ieg0 Lq p
City n R State NG Zip code U3
j , p North Carolina Department of Environmental Quality 1 Division of Energy.Mineral and Land Resources
!`1P= !L 512 North Salisbury Street 11612 Mall Service Center I Raleigh.North Carolina 21699-1612
;,-'..-,,,a,i, !/ 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 authority to sign and subm' reports for the organization.
As the Responsible Official,I, vo!'!✓I Yef .L (printed name),
have the authority to enter into this Agreement f
Arkt.e, /HG, (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, -./© �'1 +''es/�� Z (printed name),have read,
understand,and accept the terms and conditions of'rfie stormwater permit(s)for which i
am the Responsible Official.
Res onsible Official Sig ture
(kJ di/hi- /0A/022
Title Date
Stormwater Permit Delegation ofSignalory Authority Form
Page 3

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 L, Lamb
Delegated Party Title
ENV'ROPI MFNTAL SpEc2AL 3.51
Permit Number(s) Al C. G 060 3 3 6
Email Address: J Ictrn6 m Phone
�prCsAAy. -Par z .c0m 110- Sgb-58-iLI
Mailing Address (',O. Sok '13e
City Cis rtun State 14 Zip code 22321
Signature of Delegated Party � %.ni;6
indicating acceptance of 9aPlA0 Signatory Authority:
Date io/3o/23
Delegated Party Name tni1J/ILL-- N, gAg8-rvoT
Delegated Party Title galiOk P MAA lku-taitX1r /9 gGeNcN>
Permit Numher(s) Al CG 0 6 0 3 3(o
Email Address: Way Istabol. teres4aye ,care Phone 9/0,596•51,1z
Mailing Address j?D Fo%. y38
City 0/A/704 State 1,4L Zip code ZP327
Signature of Delegated Party
indicating acceptance of _. 1 /21(4—
iJ
Signatory Authority:
Date /d f 0/20Z3
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
Stormwater Permit Delegation of Signatory Authority Form
Page 2