NCG030056_SW Permit DOSA_20260505

_E Qi#, , Division of Energy,Mineral, and Land Resources FOR AGENCY USE ONLY
mem o.c�tai, Date Receivedor, NErbi�, �e, a„\ � Land Quality Section/Stormwater Program Year Month Day
`•+ National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownership of the facility has changed,
do NOT use this form. Instead, you must fill out a Name-Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual"mean?
The person is either:
• the responsible corporate officer(for a corporation);
• the principle executive officer or ranking elected official (for a municipality,state,federal or other public
agency);
• the general partner or proprietor(for a partnership or sole proprietorship);
• or,the duly authorized representative of one of the above.
1) Enter the permit number for which this change in Legally Responsible Individual("Owner Affiliation")
applies:
Individual Permit (or) Certificate of Coverage or No Exposure
N C S N C G 0 3 0 0 5 6
2) Facility Information:
Facility name: Gilbarco Inc.
Company/Owner Organization: Gilbarco Inc.
Facility address: 7300 West Friendly Ave
Address
Greensboro NC 27410
City State Zip
To find the current legally responsible person associated with your permit,go to this website:
https://deq.nc.gov/sw/ Navigate to the "NPDES Industrial Program" section and run the Stormwater Permit
Contact Summary Report for your permit number.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Sebastian Hatch
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: Andre Gomes
First MI Last
Page 1 of 2
Last revised 20 Feb 2022

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Head of Operations - Greensboro
Title
7300 West Friendly Ave
Mailing Address
Greensboro NC 27410
City State Zip
(336 ) 547-5000 [e-mail]
Telephone E-mail Address
( )
Fax Number
5) Reason for this change:
A result of: D Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If oilier please explain:
The certification below must be completed and signed by the permit holder.
Note: 40 CFR 122.22(c) requires an original signature (not digital)
PERMITTEE CERTIFICATION:
I, Andre Gomes ,attest that this application for this change in Owner Affiliation
(person legally responsible for the permit)has been reviewed and is accurate and complete to the best of
my knowledge. I derstand that if all required parts of this form are not completed,this change may not
be processed.
C;c1c. /
Signature Date
PLEASE SEND THE ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHANGE FORM TO:
DEMLR- Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh,North Carolina 27699-1612
For more information or staff contacts,please call(919)707-9220 or visit the website
at: http://deq.nc.gov/sw
Per NC General Statute 143-215.6B (i),any person who knowingly makes any false statement,representation,or
certification in any application,record,report,plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article . . . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Page 2 of 2
Last revised 20 Feb 2022

cs
' ',',
ROY COOPER ' 14l '.,i Governor i-
Nt.MARY PENNY KELLEY
Secretory •ate ,.,s
WILLIAM E.TOBY VINSON,JR 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 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 Gilbarco Inc.
Responsible Official Name
Andre Gomes
Responsible Official Title: Head of Operations- Greensboro
Email Address: [e-mail] Phone [phone]
Mailing Address 7300 West Friendly Ave
City Greensboro State NC zip code 27410
QNorth Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
���/// 512 North Salisbury Street 11612 Mall Service Center I Raleigh,North Carolina 27699 I6I2
tirn4rr.r....A rr+ .+ aw� 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 John Burke
Delegated Party Title Sustainability Manager
Permit Number(s) NCG030056
Email Address: [e-mail] Phone [phone]
Mailing Address 7300 West Friendly Ave
City Greensboro State NC Zip code 27410
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 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 Zip code
Signature of Delegated Party
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 authority to sign and submit reports for the 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 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, Gilbarco Inc. (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
Res sible cial Signat
Head of Operations - Greensboro cc,c
Title Date
•
Stormwater Permit Delegation of Signatory Authority Form
Page 3

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