NCS000435_MS4 Annual Report (2023-24 FY)_20240829

ROY COOPER
Governor `
It'i _r r 2=
ELlZAl3E'l'H S,RISER �.ad
Sccretar} 'y' 6sa3 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.
• Fora partnership or sole proprietorship,the Responsible Official shall be a general partner or the
proprietor,respectively;or
• Fora 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: NCDEMLRStormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizat•ional Entity City of Asheville
ResponsibleOfficial Name .
Debra Campbell
Responsible Official Title: City Manager
Email Address: ..': Phone
.. •• :. : . [e-mail] 828-S29-S604
Mailing Address • :
• PO Rox 7148
City :: .. .• . State Zip code
Asheville NC 28802
North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
512 North Salisbury Street 11612 Malt Service Center I Raleigh,North Corollna 27699-1612
Volt 1 ca:r tly DE
�
1.•-etir•hn + A �� 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 Amy Deyton
Delegated Party Title Interim Director, Public Works
Permit Number(s) NCS000435
Email Address: [e-mail] Phone [phone]
Mailing Address PO Box 7148
City Asheville State NC Zip code 28802
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date 1,2 - 20
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
Mailing Address
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 authority to sign and submit reports for the organization.
As the Responsible Official,I, Debra Campbell (printed name),
have the authority to enter into this Agreement for
the City of Asheville (Owner/Organization Name).
I request that the DENIM 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, Debra Campbell _ (printed name),have read,
understand,and accept the terms and conditions of the stormwaterpermit(s)for which 1
am the Responsible Official.
/t"-- 6474
Responsible Official Signature
City Manager --- e
0 6 .2n , z,j
Title Da
Stormwater Permit Delegation of Signatory Authority Form
Page 3

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, Debra Campbell (printed name), have the authority to enter into this Agreement
for the City of Asheville (Owner/Organization Name). I request that the DEMLR Stormwater Program allow
Derek Wainscott (printed name), acting in the capacity of the Stormwater Administrator, to submit the
Stormwater Annual Report related to Stormwater Permit NCS000435 on my behalf.
I acknowledge that I, and Derek Wainscott work at/for my organization and have authority to act for purposes
of the NCDEQ's electronic document Systems.
0 r
21,/_24..2 y,
Responsible Official Signature D to
City Manager
Title