NCG050174_Owner Affiliation Change_20240415

ROY COOPER $(,; 1,11*.79,
Governor w
ELIZABETH S.BISER
Secretary "14 tii;volgo
DOUGLAS R.ANSEL NORTH CAROLINA
Interim Director Environmental Qualify
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 theresponsibility 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 amunici pal ity,State,Federal,or other public agency,the Responsible Official shall be either a
principal executive officer[City/County Manager]or ran king 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
Georgia-Pacific Corrugated, LLC f.
Responsible Official Name
Sam Walls
Responsible Official Title
Area Operations Leader
Email Address: Phone
samuel.waltslgapac.com 276-670-3429
Mailing Address
200 McDowell Road
City. '' .;> s:, .' ..•::..; `,;`' State Zip,cede.::>:':
Asheboro NC 27205
North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
Airr�� h, 512 North Salisbury Street 11612 Mall Service Center I.Raleigh,North Carolina 27699-1612
ca.,i M,Eortta .mm+i:imair, 919.707.9200

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, a Wet_ s _ (printed name),
have the authority to enter into this Agreement for
G e.oi' tc, l c- c,Zft. - Co/NSc-4-1d1 r! t- L (Owner/Organization Name).
I request that the DEMI,R 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, SA.IA" We $ (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
4(4.4 s ec,ctl x y1/2s/20
Title Date •
Stormwater Permit Delegation of SignatoryAuthority Form
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