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HomeMy WebLinkAboutNCS000096_SW Permit DOSA_20231005 n, i I Fir ROY COOPER r Govemcr 5 ELIZABETH S.B1SER � ' 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 delegatin signature authority does not relieve the Permit Owner from the responsibilit 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 1 bo,Lr'e, V. S -=---c_ . Responsible Official Name ,, /. C.0{- �0 �`nQX cl ci,,�Gt ti S c- Responsible Official Title: 72 �� Email Address: LI:ilitone `10y,134{,2.11I .iris\cpL.�r,d Uu s r . r{� 1e.. Coke Mailing Address ALA to a-`O\i C\e)\, , kv\ D y• City State NL Zip code I 2S08G 1h JS G.i Q,?), North Carolina Department of Environmental Quality Division of Energy,Mineral and Land Resources NC ,C DE 512 North Salisbury Street 11612 Mail Service Center I Raleigh,North Carolina 27699-1612 i•.r+s+r...�s.wr� /`" 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 � , 20 -� Delegated Party Title C c.)nkivN0- ��0\lE 52 c0 c S 4, tACtN�c oS- PermitNumbers) NGSdo00c16 �) 31‘o4-{dl Email Address: � � ,hervN e.Ze,0\no Afx 2..a Phone 6180.5S 13 Mailing Address kl a � ^� ls City �l State p Zip code 2gO 4 ,�c� moon 8 Signature of Delegated Party indicating acceptance of 7,17 Signatory Authority: 4� Date 1� 1 � / 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 Delegated Party Name Delegated Party Title Permit Number(s) Email Address: Phone Mailing Address City State I 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, CAA 1 `�\ds0�"�eC T Cti\nao3\4cks (printed name), have the authority to enter into this Agreement for A\�;.2lnnGt,r\-12- U. S G • (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. I ' By submitting this application,I,CAfi - L �1/G.v U.S\40\J (printed name),have read, understand,and accept the terms and conditions of the stormwater permit(s)for which I am the Responsible Official. ___ ___,- r.)C-......---<--------. Responsible Official Signature Q i re_J3r !0/c1/Z-3 Title Date Stormwater Permit Delegation of Signatory Authority Form Page 3 ti t