NCS000093_DOSA Form_20240425

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NC Department of Environmental Quality
1110''111 "'::` Division of Energy, Mineral and Land Resources
Ctl4r rn0drjuulit.
Stormwater Permit Delegation of Signature Authority
Form Directions are in red.
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 for
permit compliance.
The permit Owner is 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].
Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with ermit conditions.
Organization Name: BRP ING
Responsible Official Name: CURTIS TAYLOR
Responsible Official Title: SITE MANAGER
Email Address: [e-mail] Phone: [phone]
Mailing Address: 1211 Greenwood Road
City: Spruce Pine State NC Zip: 1 28777
Stormwater Delegation of Signature Authority Form
Page 1
A. Persons to Receive Signatory Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.

Delegated Party Name: Joseph Aaron Jenkins
Delegated Party Title: EHS
Permit Number: NCS000093
Email Address: [e-mail] Phone: [phone]
Mailing Address: 1211 Greenwood Road
City: Spruce Pine State: Zip 28777
NC
Signature of Delegated Party
Indicating acceptance of Signatory
Authority: �j�--
i
Date: 4-23-2024 Z j Z2
Delegated Party Name:
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Delegated Party Title:
Permit Number:
Email Address: Phone:
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Mailing Address:
City: State: Zip
Signature of Delegated Party
indicating acceptance of Signatory
Authority:
Date:
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Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address: Phone:
Mailing Address:
City: State: Zip
Signature of Delegated Party
indicating acceptance of Signatory
Authority:

Date:
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address: Phone:
Mailing Address:
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City: State: Zip
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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, �.. *L:5 41 Ad 4or" (printed name),
have the authority to;ennter into this Agreement for
(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, i r� s J ve ®r (printed name),
have read, understand, and accept the terms and cond 'ons of the stormwater permit(s) for
which I am the Responsible Official.
Respons>K -Offidu l s'gna1tutr/e
Title Date

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Stormwater Permit Delegation of Signatory Authority
Form Page 3