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HomeMy WebLinkAboutNCG210406_SW Permit DOSA_20230711 ROY COOPER, DOUGLAS f..AN El r t 'H CAROL INA tnxzry rL?uet2:::d ftt:?'ainnent&a1 QUOtity Stormwater Delegation of SignatureAuthority 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 Godfrey LurrtbAr Company Responsible Official Name Barry Godfrey Responsible Official Title: President Email Address: 3rrry©clodfre lu nib er.cor; Phone704.l' s,f Mailing Address O> City State Zipcode t rig( tie, 2868 tar t rra Der,erDneKt eat t-nvrru sn,rf f gala} Divtr,#ax t c r err ry ,4 rm. &and f s,d R ,c,tt'— lz d2 _,gp.=` .i r 5tf eeg 1,612 Mali Se-v r,Conter 1 E dei 1.. rar2lt Carolaul L{ it l2 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 Barry Godfrey Delegated Party Title resI ent Permit Number(s) NCG210406 Email Address: Barry c godfreyl mber.corr Phone 704.873.0832 MailingAddress { Box 615 City Statesville State a:e Zip code 28687 Signature of Delegated Party indicating acceptance of Signatory Authority: Date 7/111/2 02 'j Delegated Party Name Delegated Party Title Permit Number(s) Email Address: Phone Mailing Address City 1. State zip code [ Signature of Delegated Party indicating acceptance of Signatory Authority: Date Delegated Party Name Delegated Party Title Permit Nunber(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. Barry Godfrey As the Responsible Official,I, (printed name), have the authority to enter into this Agreement for Godfrey Lumber Company (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. Barry Godfrey By submitting this application,I, (printed name),have read, understand,and accept the terms and conditions of the stormwater permit(s)for which I am the Responsible Official. Responsible Official Sign.,,,,, President 07/11/ 023 Title Date Stormwater Permit Delegation of Signatory Authority Form Page 3