NCG050470_DOSA_20260710

ROY COOPER /
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Govemor
MARY PENNY KELLEY * "•_°" . a �s i'�
SQUAW °
Secretary
WILLIAM E. TOBY VINSON, JR NORTH CAROLINA
Interim Director Environmental Quality
A
Stormwater Delegation of Signature Authority Form (40SA)
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 ddoes 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: NCDEMLR Stormwater
Program, 1612 MSC, Raleigh, NC27699-1612 'NC�osdU 90
Name of Organizational Entity
MM Packaging US Inc
Responsible Official Name
Carl Bhedwar
Responsible Official Title:
Managing Director MM. rap
Email Address:
[e-mail]
PhonT919-437-1249
MailingAddress
1000 Ccc Drive
City
Clayton
State
I
INC
Zip code
27520
North Carolina Department ofEnvironmental Quality I Division of Energy, Mineral and Land Resources
512 North Salisbury Street 1 1612 Mail Service Center I Raleigh, North Carolina 276991612
a..ar� Jr►"� 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
Liam Falter
Delegated Party Title
Consultant
Permit Number(s)
NCG050470
Email Address:
[e-mail]
Phone
919-406-4267
MailingAddress
2101 Gateway Centre Blvd #200
city
Morrisville
State
NC
I Zip code
27560
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
S
7
Delegated Party Name
Darrell Pierce
Delegated Party Title
HSE Manager
Permit Number(s)
NCG050470
Email Address:
[e-mail]
Phone
919-902-9581
MailingAddress
1000 Ccc Drive
city
Clayton
State
NC
Zip code
27520
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 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,
Carl Bhedwar
have the authority to enter into this Agreement for
Mm Packaging US Inc
(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,
Carl Bhedwar
(printed name), have read,
understand, and accept the terms and conditions of the stormwater permit(s) for which I
am the Responsible Official.
Responsible Official Signature
M;_� /1-f 011-r-dC111- b1l -
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3