NCG030238_SW Permit DOSA_20231228

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ROY COOPER - a :
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Governor 6'\ L i-f, _' R,
ELIZABETH S.BISER �\ 1- `'14:'.a=�
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 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].
Please mail the DOSA Form with original wet signatures to: NCDEMLR Stormwater
Program, 1612 MSC, Raleigh,NC 27699-1612
Name of Organizational Entity Siemens Energy Inc
Responsible Official Name Cory Phillips
Responsible Official Title: Facility Manager
•
Email Address: [e-mail] Phone [phone]
Mailing Address 3050 Westinghouse Rd.
City Rural Hall State NC Zip code 27045-4699
D_E Q A North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
512 North Salisbury Street 11612 Mall Service Center I Raleigh,North Carolina 27699-1612
CMTH Cfv OUNA
Department nr[>,mn Dual' 919.707.9200

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 Van Sullivan
Delegated Party Title EHS Specialist
Permit Number(s) NCG030238
Email Address: van.sullivan@siemens-energy,com Phone [phone]
Mailing Address 3050 Westinghouse Rd.
City Rural Hall State NC Zip code 27045-4699
Signature of Delegated Party
indicating acceptance of
•
Signatory Authority:
Date 12/28/2023
Delegated Party Name Srikanth Parvathaneni
Delegated Party Title Quality and EHS Manager
Permit Number(s) NCG030238
Email Address: [e-mail] Phone [phone]
Mailing Address 3050 Westinghouse Rd.
City Rural Hall State NC Zip code 27045-4699
Signature of Delegated Party •
indicating acceptance of
•
Signatory Authority:
Date 12/28/2023
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

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, Cory Phillips (printed name), have the authority to enter into this
Agreement for
Siemens Energy Inc (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, Cory Phillips (printed name), have read,
understand, and accept the terms and conditions of the stormwater permit(s) for which I
am the Responsible Official.
Responsibl- Of it Signature
Facility Manager (gla /: .3
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3