NCG050470_DOSA Form_20240308

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Stormwa ter Delegation of Signature Authority Form (DOSA)
This form stroll be used to delegate signature authority from the permit Owner(Perntsttee) to
another party, Only the Responsible Official defined below may submit permit applications and
reports required by the permit (such as Data Nonitoring Reports and Annual Reports) until this
form is completed and submitted to the DEMLR Storrr't^'ater Programsimiature author 1,� dues "US
permit campliance.
Perinitoyne The legal entity to whichfwhnm a permit has been issued and maybe an individual
Reap organization sibl ci such as a company or me the Ie al ig ernment agency. Every owner is a u e authority requirements in 4O CFR122.22 to ►re a
Responsible Official whom g
summarized below:
Fora corporation.the Responsible Official shall bea president,secretary,treasurer,orvice president
in charge of a principal business function,oranother individual who perforrns similar Functions For
the corporation.or the manager ofone or more manufacturing,production,or operating Facilities
wh.o is authorized to make management decisions about the faciJity operation
Fora partnership or sole proprietorship,the Responsible Officialsha)l beageneml partnerar the
proprietor.respectively,or
For a municipality,State,Federal,or other public agency.the Responsible OfftcW shall be either a
principal executive officer pty/County Manager)or ranlongelected official[MaYorl.
Please mail the DOSA!Form with orWnal wet signatures to: NCREMLRStormwater '
Program, 1612 MSC,Raleigh, MC 27699-1612
Name of Organizational EntitY MM Packaging US Inc.
Responsibleumcial Name Gary Wallace
Responsible official Title: Site Director Operations
Email Address: "hone 919-437-1249
gary. al Isce[ rn1~n.graup
MailingAddress 1000 CCC Drive
Oil' Cfayton State INC 2iFscode 27520
North C�rWru Uepartme*+t of Fmtranncritrl Qudlx I OhlsM,n d Eneryy,kfnerN and Lana Rrivcma
w pkxlh spkb wy 5tirw I ima ma kyviet reenter 14W Mh North CwD*w ZWM-Ibll
a..r� f"� 914.T07.42QU

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 Marne Darrell Piero
Delegated Party Title HSE Area Manager
Permit Number(s) NCG050470
Email Address; [e-mail] Phone [phone]
Mailing Address 1400 CCC Drive
State NC zip code 27520
City Clayter�
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party game Lindsay Fletcher
Delegated Party Titie Environmental Consultant
Permit Number(s) NCGO50470
Email Address: ([e-mail] Phone [phone]
MailingAddress 200 Regency Forest Drive
City Cary State NC zip code 27518
Signature of Delegated Party r
i ridi cating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Parry Title
Permit Numher(s)
Email Address, Phone
Mailing Address
City State zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Storinwater Permit Delegation of Signatory Authority Form
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B. Responsible Official Signature
The Responsible Official,as identified in accnrdancewith 40 CFR 172.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official,1, Gary Wallace-- (printed name),
have the authorityto enter into this Agreement for
MM Packaging US Inc.
(Qnerf()rganitation Dame).
1 request that the DEMLk Storm aterProgram include the persons listed in Part A of'this
farm signatory authority for the above-named permit.
I acknowledge that[,and the persons listed in Part A ofthiis form workat/for my
organization and have authority to act as a signatory for purposes ofthe NCD]EQ`s
electronic docu ment systems.
Gary Wallace
By submiLdng this application,I, (printed name),have read,
understand,and acceptthe terms and conditions of the stormwaterpermit(s) for which I
am the RKonsle Official.
'�; 1111ex141Z1
spo able fficial Signature
Site Director Operations
Ti fE date
Stormwater Permit Delegation of Signatory Mtho rity Form
Page 3