NCG030004_SW Permit DOSA_20230726

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 KI/-�r IC ` Ir'1��r' 1 cj
l/ C 1 1 �''1
Delegated Party Title C 1 kS NAO V t1
Permit Number(s) l-T V 1 l 4
Email Address: e i(ilr o . c%�'�ii Phone '134-%- A S LT
Mailing Address %" Y�S �� �"J` 1
q4Ir.) .lonce A ;k,i1Any, _
City C \, ui v \ok C State ` ( Zip code 1C}1'l
Signature of Delegated Party Y � �
indicating acceptance of �`2/��6�'L /
Signatory Authority: L/
Date —1 f 7 �� VO i
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
Mailing Address
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Stormwater Permit Delegation of Signatory Authority Form
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