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HomeMy WebLinkAboutNCG030175_SW Permit DOSA_20240807 STATE,- V7- -f era R . ROY COOPER (*1 y Governor ELIZABETH S.BISER ` nq Secretory .'�`+, N+, 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: NCDEMLRStormwater Program, 1612 MSC,Raleigh, NC 27699-1612 Name of Organizational Entity Ni 0 49 4r COer v1��l AResponsible Official Name do Nil ,������S M r Responsible Official Title: Di r—r(—�p� of ()7-er4-i 0� S Email Address: ., dam, dder q544. lti� Phone rqi p,t_Z _Z 51 I Mailing Address 417100 l O0 W 6� �a 3� �� City (' It 01001/1 -100 I State Nc Zip code NorthNorth Carolina Salisbury DepartmentStreetI oI612f EnvironmentalMllService Center I Ral Quality I Dlvkloeigh nNurth of Energy, Caro Mineral and Land Resources J/p 512a , na 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 4 i (,�okr\a ZIA.1i Delegated Party Title E 0 1\A a NO cv i/ Permit Number(s) ° NCC�US0DU() Ccoc Nt -iC� S j75,. Email Address: \li et 0(1 0 • Phone F Mailing Address 2100 1c f, igyocl q r-r-f- City E.", Z4b°I1� 417LAA1 State ' Nt Zip code 2C2 j 5 7 Signature of.Delegated Party indicating acceptance of - Signatory Authority: Date c f .7 /Zo Z 9 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 Numbers) 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, f\Ac.M �«AAQ.r (printed name), have the authority to enter into this Agreement for 6'ynG.pexr C0 r-rk•V: (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, } uni\ Ligac's (printed name),have read, understand,and accept the terms and conditions of the stormwaterpermit(s)for which I am the Responsible Official, a_v-z Responsible Official Signature b`: 0porekans Title Date Stormwater Permit Delegation of Signatory Authority Form Page 3