NCG210450_SW Permit DOSA_20230818

a
A e
ROY COOPER C ` .
Governor M
ELIZABETH S.BISER
Secretary
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_apar_tnership_nr_so1e prnpri pro rchi-p,thPResponsibl_e-OfficiaLshall_be_ageneral_partnernr 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 f n
GN V IVA rCLC.ETS 5t psoN LLC
Responsible Official Name
3oSH.4 G4)fALLEy
Responsible Official Title:
PLANT MANAGif Q
Email Address: Phone
,Noshva.wcerlcy eenvtva6iomass.0 260- 150 -Ding
Mailing Address
5 Cow!NEcT0& Ro4p OS ll7
City State Zip code
FA 1 So14 N L 283y I
Q North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
D E
w �/ 512 North Salisbury Street 1 1612 Mall Service Center I Raleigh,North Carolina 27699-1612
. _
^•^��;,^�^^^.. ; /', 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 Rof3 N(SICA
Delegated Party Title 12.F CAI°NAL ENvI Ror+ENT 14u COAAP I ANGE MA/444EL
Permit Number(s) N CCA 210 S/So
Email Address: 1'06r4..Aisk-a GvvIvA ootAss.cook Phone glv.y65 0Zgg
Mailing Address
5 CON NEGTo2 0-0AD OS 1/1
City FA of.) State Zip code ze is
Signature of Delegated Party
indicating acceptance of r2CDol
Signatory Authority:
Date Auc uS't (1 2023
Delegated Party Name C -1 S GEL c.N E
Delegated Party Title E I-I S 141ANRu.E2
Permit Number(s) (C� 210 ySo
Email Address: cJ�iiS. helcher'eeNvi✓A&emAsS•coot
Phone 9$4-.34y-Y732
Mailing Address
CONNEc.7t04__ LLOAQV_S(L7- - --------- -- - -----
City isoN State Ntr Zip code 2$3,4
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date r - ii,,t //Z'
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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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, losNuA (..►Eac- Ey (printed name),
have the authority to enter into this Agreement for
ENV V PE��ET.) Set",sons LLC (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, 705t4uA. LJ At-LEy (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
Res onsi le Official Signature
ittI\ lk-fi C43€,1 /)7./Z_.?
Title Date
Stormwater Permit Delegation of Signatory Authority Form
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