NCG210411_DOSA Form_20240523

�.�.c STATE
�y
ROY COOPER
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: NCDEMLR Stormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity Profile Products LLC Broad River
Responsible Official Name Caleb Minter
Responsible Official Title: Plant Manager
Email Address: [e-mail] Phone [phone]
MailingAddress 1105 Farrington St
City Conover State NC Zip code 28613
D E Q�� North Carolina Department of Environmental Quality Division of Energy,Mineral and Land Resources
512 North Salisbury Street 11612 Mail Service Center Raleigh,North Carolina 27699-1612
NORT CAROLI+
D ^dm,tai�Iw6m'el ou.Z 919.707.9200

A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates theiracceptance of signatory authority.
Attach additional pages if you need more space.
Delegated Parry Name David Frederick
Delegated Party Title Safety Manager
PermitNumber(s) NCG210411
Email Address: [e-mail] Phone
Mailing Address 219 Simpson Street
City Conover State NC Zip code 28613
Signature of Delegated Party
indicating acceptance of
Signatory Authority: Qb2c4l
Date
i
Delegated Party Name Kim Melvin
Delegated Party Title Project Engineer-EMS
Permit Number(s) NCG210411
Email Address: [e-mail] Phone [phone]
MallingAddress 116 Hidden Hill Road
City Spartanburg State SC Zip code 29301
Signature of Delegated Party
S
indicating acceptance of
Signatory Authority: i
Date
Delegated Party Name
Delegated Party Title
j
Permit Number(s)
Email Address: Phone
MailingAddress
City State Zip code
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 authorityto sign and submit reports for the organization.
As the Responsible Official,I, Caleb Minter (printed name),
have the authority to enter into this Agreementfor
Profile Products LLC Broad River _ (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/formy
organization and have authority to act as a signatory for purposes of the NCDEQ's
electronic document systems.
By submitting this application,I, Caleb Minter (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
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3