NCG070117_DOSA_20240410

ROY COOPER
Governor
ELIZABETH S.BISER 0Secretary
DOUGLAS R.ANSEL NORTH CAROLINA
Interim Director Envfron entat Quality
Stormwater Delegation of Signature Authority Form (DOSA)
This form shall be used to delegate signature authority from the permit Owner (Permittee) to
another parry. 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 debating
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:
• 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 be a general partner or the
proprietor,respectively;or
• Fora 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�y Q(M =N 1
NRTIONAL, rNC.
Responsible Official Name
IGt:'VI N Ho2TOt.1
Responsible Official Title:
Pi-RNT MANA(jE2
Email Address: a Phone
vIN.�lofLiaNrcaKVocERA.CnM (858)Zu3-6635
MailingAddress joo TQb05TR1AL- PARK Kb I4EIJDZP-SONYIILCIN(.28
City State Zip code
µE�1p�P.SoyVtLL INC 28791
W& WE North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
CL� — 512 North Salisbury Street 11612 Mail Scrvice Center I Raleigh.North Carolina 2 76 9 9-1612
ou'r—v==�^---p•��'� 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 MAV,k KCNA1Al2D
Delegated Party Title 59- ENS q"F-9ALIST
PermitNumber(s) NCCjO-C>6CU
Email Address: tKAK4.t4lQJMA V-YOCCM,CG7r' I Phone 1 k-9)573-Z-7LI
MailingAddress 100 T..JO05TZAL 'PARy_ g
city FfF-Jjb- PS6MVIU.E I State INC I Zip code 2g-ji�j
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date o3 _ 1 y-?-Li
Delegated Party Name DOU i` D4¢6
Delegated Party Title 5i2 C EN£(Li{L15 f
PermitNumber(s) fAC4 0-70000
Email Address: DOU tRs, MC-DARES0 OOCEZA,(Ond Phone &24y58.505)
MailingAddress IUo s�D�Su�LPA�� �D
city ! Nt,�2soNV1U E State N< Zip code Zg7q�
Signature ofDelegated Party
a
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address: Phone
MailingAddress
city State Zip code
Signature of Delegated Parry
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, t<e.V1N 4C>V`MI3 (printed name),
have the authority to enter into this Agreement for
KYiXEQq Al 5�"A) UAL., !-NG. (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/formy
organization and have authorityto act as a signatory for purposes of the NCDEQ's
electronic document systems.
By submitting this application,I, KEdIN 00f:M. (printed name),have read,
understand,and accept the terms and conditions of the stormwaterpermit(s)for which I
am the Responsible OfficiaL
Responsible Officialsig�re
PLAO-C MPJfl6E9_ a3- iLI -Zy
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3