NCG060364_DOSA_20260223

Dos
70'
"O w
ROY COOPER' 1
Governor
MARY PENNY KELLEY
*`$' wN,'
Secretary
WILLIAM E. TOBY VINSON, JR NORTH CAROLINA
Interim Director Environmental Quality
Stormwater Delegation of Signature Authority Form (DO SA)
Q
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
ermit 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 N CC,06 0 369
Name of Organizational Entity
Wayne -Sanderson Farms LLC
Responsible Official Name
Paul Billingsley
Responsible Official Title:
VP -Development and Engineering
Email Address:
[e-mail]
Phone
601-649-4030
MailingAddress
P.O. Box 988
City
Laurel
State
MS
Zip code
39441
E54!r ,�y/
?North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
512 North Salisbury Street 1 1612 Mail Service Center I Raleigh, North Carolina 27699-1612
919.7070200

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
Stephanie Shoemaker
Delegated Party Title
Sr. Director of Environmental
Permit Number(s)
NCGO60364
Email Address:
[e-mail]
Phone
(501-426-1572
MailingAddress
P.O. Box 988
City
Laurel
State
MS
Zip code
39441
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Donald Genova
Delegated Party Title
Feed Mill Supervisor
Permit Number(s)
NCG060364
Email Address:
[e-mail]
Phone
[phone]
MailingAddress
3628 S Fields Street
City
Farmville
State
NC
Zip code
27828
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Wes Hail
Delegated Party Title
Live Operations Manager
Permit Numbers)
NCG060364
Email Address:
[e-mail] j
Phone [phone]
MailingAddress
1536 Smithfield Way
City
Kinston
State
NC
Zip code 28504
Signature of Delegated Party
indicating acceptance of
Signatory Authority:4111
Date
_ D /
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,
Paul Billingsley
have the authority to enter into this Agreement for
Wayne -Sanderson Farms LLC
(printed name),
(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,
(printed name), have read,
understand, and accept the terms and conditions of the stormwaterpermit(s) for which I
am the Responsible Official.
Responsible Official Signature
VP -Development and Engineering
Title
Paul Billingsley
7,1 d
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3