NCG130067_SW Permit DOSA_20241109

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ROY COOPER I
Governor
MARY PENNY KELLEY .;�
Secretary
WILLIAM E.TOBY VINSON,JR 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
1 Name of Organizational Entity el I
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Responsible Official Name
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Responsible Official Title:
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Email Address: v Phone
s i&►freifri-gSc,nock-cow. 7U' - /71 - lV C
Mailing Address f Isl1 Hwy
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City f dt ( State 'C Zip code rr
North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
f,) 512 North Salisbury Street 11612 Mall Service Center I Raleigh North Carolina 27699 1612
�� 7..\ /" 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 -kt,
Delegated Party Title Pr,.f.lan � '.1V'T0/
Permit Number(s) ' 'G G- r3 0 Cl m 6--
Email Address: VA bale-r 5;j\oat -COS Phone L/�i/_a f 0
I
Mailing Address g-11 Huy 10 /
City Ids, State Ne./ Zip code a?..1 8?
Signature of Delegated Party
indicating acceptance of
Signatory Authority: c14
Date J/r 7 ,_ C�>/
Delegated Party Name iudter
Delegated Party Title COnTvi/C.n r
Permit Number(s) IO C C-/,Od C
Email Address: ltift .ln WekL�� dr.Crrwi Phone BGt� 1
t (S1 l �s-SL 3
Mailing Address VD/J Par fcrt.oad CGI- VI- IZu
City RA it State L Zip code a 7iev
Signature of Delegated Party
indicating Authority:
Signatory Authority:
Date 11- JoZi
Delegated Party Name t �K ( j I
Delegated Party Title lCeinfta 14%4%
Permit Number(s) M C&.!3 0 6 C-1-
-Email Address: - 1MClt'APIPCrcAti-C OlvolAt"t'ahyf a 444 c10-a J f 7C/
Mailing Address 10 Aap /3I
City Jfe `� State NCd Zip code .123 4/1
Signature of Delegated Party boo/
indicating acceptance of
Signatory Authority:
Date fr-
StormwaterPermit Delegation of Signatory Authority Form
Page 2

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
Delegated Party Title
Permit Number(s)
Email Address: Phone
MailingAddress
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
Delegated Party Name
Delegated Party Title
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 authority to sign and submit reports for the organization.
J iM; J�./IC- t (printed name
As the Responsible Official,I, f (p ,)
have the authority to enter into this Agreement for
Vlv R,dc td �hJ CJ (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, c) i*;t irc PI (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
ice._
R sponsible Officia Si ature
elf Act„ 01-14_
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3