NCG030047_SW Permit DOSA_20240124

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ROY COOPER
Cizrvernor *'"
ELIZABETH S.BISER
:Scrretaty
DOUGLAS R.ANSEL NOWT 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: NCDEMLRStormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity 'l �y (�` � � �` �1 I
are° nrt/e�lha S e4- s �00. p K-L Wary.
Responsible Official Name
141ee6o,e.lcic_son
Responsible Official Title:
v t' S0. e_S 't-b 2Ocryler t o as
Email Address: rr► c11ak t i o-ek son Phone
ck(0100_Iskyas._3are . e-orn 91a1,61$9 - 11077
Mailing Address
1315 Uu+\ e_i- Ce -1-cr 1-.)r ve—
City State Zip code
Ste, t\d al 57 7
ink .*". North Carona Department of Erma onmental Q;uafity Omsk-PI of Energy,M Herat and Land Resources
.r.
12 North Salisbury Street 116l2 ad Service Center Raleir lb,North Carolina"27Mg9 1G12
M,,;;,..,ta n,....\deed' 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 SoSct W O.rm
Delegated Party Title �R D l
Permit Number(s) (VL+G O 3 00 4
Email Address: Phone
SuSahwo.rmu'� @g\o6o�1s�wacc-.cam,,,, qi9-989-1-TO 9
Mailing Address `r, ()title±
City Srvlp_AickState Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority: e1,14../ OJX-( )''11alLfY)t-u
-11-14-
Date D/ /i '7 /a oa sl
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 State Zip code
Signature of Delegated Party
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 cm.122,Z2,is the appropriate
individual with the authority to sign and submit reportts for the organiratlon,
As the Reslrnnsible(lftici al,I,_kle,-?10..C.1 .�aq-}. r1 _ (printed name),
have the authority to enter into this Agreement for
Vccl 4'1 i1,1d, �(1 'S+eyiware; (Owner/OirganIzation Name).
• I requestthnt the DEML:K Stormw•ater Program include the persons listed In Part A of this
term signatory authority for the above named permit.
I acknowledge that',and the personwslisted In Pall A of this form work at/for my
organization and have authority to act as a signatory far purposes of the NCUEQ's
electronic document systems.
By submitting this application,I, l to c.\ ¢,c. (printed name),have read,
understand,and accept the terms and conditions of the stormwaterpermtt(s)for which!
am the ResponsibleOft-i neit\ ,
r
1 q ,
•
% s
Resnorsibie Official Signatulla'
le
i e 4i,s 4...tro.,60,- ffrr- I I 20.'71,` i 2 *f_
Title Date
IP
StormwatcrPennit Delegation of Signatory AuthoriiyForm
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