NCG030611_SW Permit DOSA_20240830

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ROY COOPER ` t*
ELIZABETH S.BISER •.: .
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DOUGLAS R.ANSEL NORTH CAROLINA
lntrnm Dint i-v 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 Progress Rail Winston-Salem
Responsible Official Name
Tony M. Wings
Responsible Official Title: Director of Operations
Email Address: Phone
[e-mail] 708-387-5306
Mailing Address 2950 Temple School Rd
City Winston Salem State NC Zip code 27107
D_E North Carolina Department of P.nvoonmental Quality Division of Energy,Mineral and Land Resources
512 North Shcnbur' Street tbl?Mail Servo a Center Rakklh.North Carolina 27b49 IM1
----•t �-+� /i 914 707 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 David M. Brecheen
Delegated Party Title Manager, EHS
Permit Number(s) NCG030611
Email Address: dbrecheen©progressrail.com J Phone [phone]
Mailing Address 2950 Temple School Rd
City Winston Salem State NC Zip code 27107
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date 08/23/2024
Delegated Party Name Jessica Lamb
Delegated Party Title EHS Specialist
Permit Number(s) NCG030611
Email Address: [e-mail] Phone [phone]
Mailing Address 2950 Temple School Rd
City Winston Salem State NC Zip code 27107
Signature of Delegated Party
indicating acceptance of i
Signatory Authority:
Date 08/23/2024
Delegated Party Name James W. Willard II
Delegated Party Title Vice President
Permit Number(s) NCG030611
Email Address: [e-mail] Phone [phone]
Mailing Address 132 W. Statesville Ave
City Mooresville State NC Zip code 28115
Signature of Delegated Party �
indicating acceptance of �l/- �il/ GL�t��+
Signatory Authority:
Date 08/23/2024
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, Tony M. Wings (printed name),
have the authority to enter into this Agreement for
Progress Rail Winston-Salem (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, Tony M. Wings (printed name),have read,
understand, and accept the terms and conditions of the stormwaterpermit(s) for which I
am the Responsible Official.
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4e.4-
Re onsible Official ure
g
Director of Operations 08/23/2024
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3