NCG020003_SW Permit DOSA_20251121

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ROY COOPER 4! M1•r Governor r
MARY PENNY KELLEY »1,.r -
Secretory ' ';000.
WIWAM E.TOBY VINSON,JR NORTH CAROLINA
Interim Dfrerror 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:
• Fora 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: NCDEMLRStormwater
Program,1612 MSC,Raleigh,NC 27699-1612
Name of Organizational Entity
Wake Stone Corp.
Responsible Official Name ..i
J 4." Y'e. .,i,
Responsible Official Title: , i7 in ivt
Email Address 1 Phone eo,+4,,w,0;---&,
Mailing Address 1
City 1�1I1 ��ai� Vic:State Zip code
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D E Co North Carolina Department of Erwtronmerrcel Quality i Dlvkion of Energy,Mineral and land Resources
es
S12 North Salisbury Street 1612 Mall Service Center I Italetgh North Caroltna 27699-1612
r\/'" 919.7079200

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 Tony Johnson
Delegated Party Title Environmental Engineer
PermitNumber(s) NCG020001, NCG020003 ,NCG020030 ,NCG020031
Email Address: Phone
[e-mail] 704-547-7076
Mailing Address 11020 David Taylor Dr. Suite 400)
Charlotte State NC Zip code 28262
Signature of Delegated Party
ind
cating
ance of
Signatory
yAuthority:
_Signatory Authority: ✓J
Date 9 //g/202
Delegated Party Name
Sarah Harris
Delegated Party Title Environmental Specialist
PermitNumber(s) NCG020001. NCG020003 .NCG020030 .NCG020031
Email Address: [e-mail] Phone [phone]
Mailing Address 11020 David Taylor Dr. (Suite 400)
City Charlotte State NC Zip code 28262
—Signature of Delegated Party
indicating acceptance of
Signatory Authority: , 44rtiuuto
Date 9 i q 20 2 S-
Delegated Party Name Cole Atkins
Delegated Party Title Geology Services Manager
Permit Number(s) NCG020001. NCG020003 .NCG020030.NCG020031
Email Address: [e-mail] Phone [phone]
Mailing Address 6821 Knightdale Blvd.
City Knightdale State NC Zip code 27545
Signature of Delegated Party
indicating of goLitSignatoryAuthority: ^/'�,
Date vao d.o a S
Stormwater Permit Delegation of SignatoryAuthority Form
Paoe 7

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.
Y
As the Responsible Official,I, J �v'"' (printed name),
have the authority to enter into this Agreement for
YYi`��� `�' `J(") CO(17 (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.
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By submitting this application,I, J Yan d.- (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
Responsible Off-ial Signature
Y 7/6/14
Title Date
Stormwater Permit Delegation of SignatoryAuthority Form
Pao 2