NCC243165_FRO Submitted_20241014

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ROY COOPER 1 hiji,i
Governor :
ELIZABETH S.BISER +� �;
Secretory
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 Greenville Utilities Commission
Responsible Official Name Anthony C. Cannon
Responsible Official Title:
General Manager/ CEO
Email Address: [e-mail] Phone [phone]
Mailing Address PO Box 1847
•
City Greenville State NC Zip code 27835
NorthDepartment of Environmental Q I of Mineral Land Resources
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512 North SalisburyDepa Street 116 12 Mail Service Centeruality I Raleigh North CarolinaEnergy. 27699and-1612
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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 Ryan Clark
Delegated Party Title Vice President
Permit Number(s) PA-003801
Email Address: [e-mail] I Phone [phone]
Mailing Address 4525 Main St, Suite 1000
City Virginia Beach State VA Zip code 23462
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date 03/27/2024
Delegated Party Name Chris Margaritis
Delegated Party Title Analyst
Permit Number(s) PA-003801
Email Address: [e-mail] Phone [phone]
Mailing Address 4525 Main St, Suite 1000
City Virginia Beach State VA Zip code 23462
Signature of Delegated Party 62/7
indicating acceptance of -
Signatory Authority:
Date 03/27/2024
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, Anthony C. Cannon (printed name),
have the authority to enter into this Agreement for
Greenville Utilities Commission (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, Anthony C. Cannon (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
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Responsible Offi al Signature
General Manager/CEO q- r�lF
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name: NC 11 North Natural Gas Main Extension
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name below under which
you applied for funding through the Division of Water Infrastructure (DWI).
Is Project ARPA Funded ARPA Project Name ARPA Project#
No
2. Location of land-disturbing activity: County: Pitt City or Township: Greenville
Highway/Street: NC 11 (N. Memorial Drive) Latitude: 35.660928 Longitude: -
77.363423
3. Approximate date land-disturbing activity will commence: 6/3/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11.92
6. The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes-Will be Mailed or Hand-Delivered
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Greenville Utilities Commission E-mail Address: [e-mail]
Phone: Mobile:
9. Landowner(s)of Record:
Landowner(s) of Record
Name Email Business Phone Mobile Phone
NCDOT
Physical Address Mailing Address
Street 1 City State Zip Street 1 _ City State Zip
1501 Mail Service Raleigh NC 27699 1501 Mail Service Raleigh NC 27699
Center Center

Part B.
1. Company(ies) who are financially responsible for the land-disturbing activity (Provide a comprehensive list of all
responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is an individual(s), the
name(s) of the owner(s)may be listed as the financially responsible party(ies).
Primary Financially Responsible Party
Company Name Email Business Phone Mobile Phone
Greenville Utilities Commission [e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
P.O. Box 1847 Greenville NC 27835 P.O. Box 1847 Greenville NC 27835
Additional Financially Responsible Parties
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form the
landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation control
plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Registered Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent who is registered on the NC Secretary of State business registry:
North Carolina Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
Kimley-Horn chris.margaritis@kimley- 757-213-8600
horn.com
Physical Address Mailing Address
Street 1 City _ State Zip Street 1 City State Zip
4525 Main St, Virginia VA 23462 4525 Main St, Virginia VA 23462
Suite 1000 Beach Suite 1000 Beach

Additional Details
1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water; NSW: Nutrient
Sensitive Waters
2. Was Express Review Requested: No
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.