NCG080893_DOSA_20240514

STATE,,
R .�y
ROY COOPER
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Governor'
ELIZABETH S.BISERf
'fin a n
Secretary *�°Q(Mw�°
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:
• 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.
• 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: NCDEMLR Stormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity �;r}� of f �reet'?Shor0
Responsible Official Name l�
Responsible Official Title:
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Email Address: hone
fichard e love,4 d reev15bora-hey vP 33� �13- I$
Mailing Address 4101 D ,t
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City State Zip code
�reeosbory /4/G ;27406
North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
512 North Salisbury Street 1 1612 Mail Service Center I Raleigh,North Carolina 27699-1612
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rv,nnwm of em,,,,,,„vmm nsu'v 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 S'gra h t' 01t OMer-
Delegated Party Title Envi ron 2 �q S e t'v'�Ge Anal s
Permit Number(s) NcCrO BO8 C13
Email Address: Sara�. /YI oYrt 0/Yt� B rf'PrlS&r�nc, P✓o ne 336-373
MailingAddress p a- �� �{✓-r &-
City 2 Oro State IvC Zip code o?74
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date ()31a 1 1�0�3
Delegated Party Name
Delegated Party Title En Vf rOY) serv/G� rlal s
Permit Number(s) /VCG OR 07g9'
Email Address: arah.l►`)Ur IY1CY Yf�1r1SkX7ro-DG. • Phone �6_373-4( $8
MailingAddress
City v'e211 bc) State /yG Zip code �7y 0
Signature of Delegated Party
indicating acceptance of
Signatory Authority: —71
Date Oa 121 ,2U23
Delegated Party Name '06IYal, 1;9010f 01-"e
Delegated Party Title ervi(e
Permit Number(s) NG 00 13
Email Address: Phone
MailingAddress 41ol k on 4�enVt
city eYlS�v`� State Yic- Zip code �-7 LA L
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date Ll
03(21 2023
Stormwater Permit Delegation of Signatory Authority Form
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B. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate
individual with the authorityto sign and submit reports for the organization.
As the Responsible Official,I, P-i C 11 — c)Y� (printed name),
have the authorityto enter 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, lC U L'Ov tt —_ (printed name),have read,
understand,and accept the terms and conditions of the stormwaterpermit(s)for which I
am the Responsible Official.
Responsible Official Signature
Eait-onawfat P m%q YT //AZLZ-3-
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3