NCG110055_SW Permit DOSA_20240306

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ASTONI
NC
Great Place. Great People. Great Promise.
February 16, 2023
NCDEMLR Stormwater Program
1612 Mail Service Center
Raleigh, NC 27699-1612
Subject: Delegation of Signature Authority
To Whom It May Concern:
Please find the attached Delegation of Signature Authority for the MS4 permit and certificates of
coverage held by the City of Gastonia regarding general industrial stormwater permits. These forms
have been signed by Mr. Michael C. Peoples, City Manager for the City of Gastonia.
The affected certificates of coverage are:
• NCG080701 Gastonia Vehicle Maintenance Facility
• NCG110055 Crowders Creek WWTP
• NCG110056 Long Creek WWTP
• NCG110125 Eagle Road WWTP
• NCG150032 Gastonia Municipal Airport
If you have any questions or comments regarding this submittal, please feel free to contact me at
704-842-5106 or [e-mail].
Sincerely,
—David Shellenbarger
Assistant WWT Division Manager Wastewater Compliance
City of Gastonia
Certified Mail: 7016 1370 0000 8337 7023
CC: Stephanie Scheringer,Assistant Director Public Utilities
Danon Lawson,Stormwater Administrator

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ROY COOPER _ ` .j-
Governor ,r ,
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: NCDEMLRStormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity
City of Gastonia
Responsible Official Name
Michael C. Peoples
Responsible Official Title:
City Manager
Email Address: Phone
[e-mail] 704-866-6719
Mailing Address
PO Box 1748
City State Zip code
Gastonia NC 28053
$,,,-,),Q North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
512 North Salisbury Street 11612 Mail Service Center I Raleigh,North Carolina 27699-1612
Deportment of Errefronmentst Ow.7;\r" 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 Danon Lawson
Delegated Party Title Stormwater Administrator
Permit Number NCS000429,NCG080701,NCG110055,NCG110056,NCG110125,NCG150032
Email Address:` [e-mail] Phone [phone]
MailingAddress PO Box 1748
City Gastonia State NC Zip code 28053
Signature of Delegated Party Impoz7,
indicating acceptance of
Signatory Authority: 'or
Date `/1/2 9
Delegated Party Name Stephanie Scheringer
Delegated Party Title Assistant Director Public Utilities
Permit Number(s) NCG110055, NCG110056, NCG110125
Email Address: [e-mail] Phone [phone]
Mailing Address PO Box 1748
City Gastonia State NC Zip code 28053
Signature of Delegated Party
indicating acceptance of
Signatory Authority: 1 e'
Date 4a 0� P`t
Delegated Party Name David Shellenbarger
Delegated Party Title Assistant WVVTD Manager Compliance
Permit'Number(s) NCG110055, NCG110056, NCG110125
Email Address: [e-mail] Phone [phone]
MailingAddress PO Box 1748
City Gastonia State NC Zip code 28053
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date 1 /CS/aaa.4
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, Michael C. Peoples (printed name),
have the authority to enter into this Agreement for
City of Gastonia _ (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, Michael C. Peoples (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
Responsible Official Signature
City Manager (,/ /.7 /0?°
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3