NCG070156_DOSA Form_20240430

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ROY COOPER
Governor *' _
ELIZABETH S.BISER ` a=.
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 maybe 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,orvice 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 otherpublic agency,the Responsible Official shall be either a
principal executive officer[City/County Manager]or rankingelected official[Mayor].
Please mail the DOSA Form with original wet signatures to: NCDEMLR Stormwater
Program, 1612 MSC,Raleigh, NC 2 7699-1612
Name of Organizational Entity SELEE Corporation
Responsible Official Name Watt Jackson
Responsible Official Title:
President
Email Address: w][e-mail] Phone [phone]
MailingAddress
700 Shepherd St
City Hendersonville State NC Zip code 28792
' 'D_EQ�� North Carolina Department of Environmental Quality lDivision of Energy'Mineral and Land Resources ,
5lAorth Salisbury Street 1 1612 Mail twice Center Raleigh.North Carolina 27699-1612
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 Parry Name Kim Melvin
Delegated Party Title EHS Engineer
PermitNumber(s) NCG070156
Email Address: [e-mail] I Phone [phone]
Mailing Address 700 Shepherd St
city Hendersonville State NC Zip code 28792
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date lr
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
MailingAddress
city State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Stormwatei Permit Delegation of&natory Authority Fgrni
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B. Responsible Official Signature
The Responsible Official,as identified in accordancewith 40 CFR 122.22, is the appropriate
individual with the authorityto sign and submit reports for the organization.
As the Responsible Official,I, Watt Jackson (printed name),
have the authorityto enter into this Agreement for
SELEE Corporation (Owner/Organization Name).
1 requestthat the DEMLR Stormwater Program include the persons listed in Part A of this
form signatoryauthorityfor the above-named permit.
I acknowledge that I,and the persons listed in PartA of this form workat/for my
organization and have authorityto act as a signatoryfor purposes of the NCDEgs
electronic document systems.
By submitting this application,I, Watt Jackson- (printed name),have read,
understand,and accept the terms and conditions of the stormwaterpermit(s)for which I
am the Responsible Official.
30�__=
Responsible Official Signature
President L2 6
r
Title Date
Stormwater Permit Delegation ot Signatory Authority Porm
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