NCG030056_Delegation of Signature Authority_20260518

SrA7r
RECEIVED
ROY COOPER Governor MAY
f
°iAY 1 <l /
MARY PENNY KELLEY < f ZR:u
secretary
WILLIAM I;TOBY VINSON,JP NORTH CAROLINA DEMLR-STORMWATER PROGRAM
Interim Dfrecror Environmental Quality pfOtM(A 511BIaU
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
anature 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 maybe 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,orvice 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 otherpublic agency,the Responsible Official shall be either a
principal executive officer[City/CountyManager]or rankingelected 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 Gilbarco Inc.
Responsible Official Name
Andre Gomes
Responsible Official Title: Head of Operations- Greensboro
Email Address: [e-mail] Phone [phone]
MailingAddress 7300 West Friendly Ave
city Greensboro State NC zip code 27410
D North Carolina Department or Environmental Quality I Division of Energy.Mineral and Land Resources
512 North Salisbury street 11612 Mail Service Center I Ralelgh,North Carolina 2 76 9 9-1612
919.707,9200
M X0.N

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 Parry Name John Burke
Delegated Party Title Sustainability Manager
PermitNumber(s) NCG030056
EmailAddress: [e-mail] I Phone [phone]
MailingAddress 7300 West Friendly Ave
city Greensboro I State INC I Zip code 127410
Signature of Delegated Party
indicating acceptance of
Signatory Authority: A�
Date t L 2
Delegated Party Name
Delegated Party Title
Permit Numbers)
Email Address: Phone
MailingAddress
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
MailingAddress
City State Zip code
Signature of Delegated Parry
indicating acceptance of
Signatory Authority:
Date
Stormwater Permit Delegation of SignatoryAuthority 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 authorityto sign and submitreports forthe organization.
As the Responsible Official,I, Andre Gomes (printed name),
have the authority to enter into this Agreement for
Gilbarco Inc. (Owner/Organization Name).
I request that the DEMLR Stormwater Program include the persons listed in PartA of this
form signatory authority for the above-named permit.
I acknowledge that 1,and the persons listed in Part A of this form work at/for my
organization and have authority to act as a signatoryfor purposes of the NCDEQ's
electronic document systems.
By submitting this application,1, Gilbarco Inc. (printed name),have read,
understand,and accept the terms and conditions of the stormwaterpermit(s)for which I
am the Responsible Official.
Res sible cial Signat
Head of Operations - Greensboro cUs�o1�7�2�
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3