Loading...
HomeMy WebLinkAboutNCGNE1608_SW Permit DOSA_20240105 ROY COOPER i L,iiNe7:', Governor ,' ELIZABETH S.BISER 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 may be 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 (, ,.k.ain del n e 14- (-lite )i✓►<- Responsible Official Name Qa 5 v , `3 1& Responsible Official Title: Vic.Q,f icsld t- 2-egi ewe Email Address: • Phone rt-envi rb @Scri. cai, $03 7g'f- 7300 Mailing Address ,/2.0 -71_ City State Sc Zip code lexi,Ton Z9073 D_E 1;. NorthCarolinaDepartmentofEnvironmental Quality I DivislonofEney,Mineral andLand Resources 512 North Salisbury Street 11612 Mail Service Center I Raleigh,North Carolina 27699 1612 a � rd 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 S. sa..,y Delegated Party Title 1=,�►U1 l CA)AN fLsn.Ac4 A rp n�n,e,.�,��, Permit Number(s) PC,G 0%0191) 0$02-912)0$O590s 080G ix,lotoun 08o93e Email Address: 3( 4n yakefeSe f, GTrr Phone 7W3Z3 gag Piper Address 5306 Pip , City PIuckQ€10rda State it_ Zip code 33f%'L Signature of Delegated Party indicating acceptance of Signatory Authority: Date i•S• 2c?A Delegated Party Name Score 0.S o-1051PC Delegated Party Title Permit Number(s) Kic.q;o o291.0/ 0%02.2 2,ClOQ9$,NE490t 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 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, 7-`1 an SM‘91.a (printed name), have the authority to enter into this Agreement for SolLM' 0 (-4" ' (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,12-y an S m'5'e( (printed name),have read, understand,and accept the terms and conditions of the stormwater permit(s)for which I am the Responsible Official. jz;e2,;() Responsible Official Signature y P. Q Estxte //5/ z y Title Date Stormwater Permit Delegation of Signatory Authority Form Page 3