NCG020814_Email_20210709

McCoy, Suzanne
From:
Sent:
To:
Cc:
Subject:
Attachments:
Good afternoon Mr. Innes.
McCoy, Suzanne
Friday, July 9, 2021 3:05 PM
inneslaw
Parr, Adam
NCG020814 Cheshire Meadows Mine
MapleSandEDMRReport.pdf
Upon review of the attached form you sent I noticed the permit number written in is the DEMLR Mining Permit (27-48),
not DEMLR Stormwater Permit (NCG020814).
If you are needing to update contact information for the Mining Program Permit, please contact Adam Parr copied on
this email.
Sincerely,
Suzanne McCoy
Stormwater Program Administrative Specialist
Division of Energy, Mineral and Land Resources
Department of Environmental Quality
512 N. Salisbury Street, Office 640K, Raleigh, NC 27604
1612 Mail Service Center, Raleigh, NC 27699-1612
919-707-3640
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has adjusted operations to protect the health and
safety of the staff and public. Many employees are working remotely or are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are
limiting public access to appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your requests by phone or
email. We appreciate your patience as we continue to serve the public during this challenging time.
pµjnir�ii of En�ronniruUI {j4,.ilwy
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: James Innes <[e-mail]>
Sent: Tuesday, June 15, 2021 5:06 PM
To: McCoy, Suzanne <[e-mail]>
Subject: Re: [External] electronic reporting
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Attached is our report. Please advise what is our next step. Thank you. James Innes
On Tue, Jun 15, 2021 at 4:13 PM James Innes <[e-mail]> wrote:
NCG020814
On Tue, Jun 15, 2021 at 3:48 PM McCoy, Suzanne <[e-mail]> wrote:

Yes, they are fillable pdfs, or you may print them and write in the information, mail to my attention.
What is your Certificate of coverage number?
Suzanne McCoy
Stormwater Program Administrative Specialist
Division of Energy, Mineral and Land Resources
North Carolina Department of Environmental Quality
Physical: 512 N. Salisbury Street, Office 640K, Raleigh, NC 27604
Mailing: 1612 Mail Service Center, Raleigh, NC 27699-1612
Email: Suzanne. mccoy(jr�ncdenr.clov
Phone: [phone]
Website: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
E
rxrn r :. Q-P
OgpN{rrw�{pl Enr,ronmenial gcisllYy
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Before printing this email, please consider your budget and the environment.
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle
your requests by phone or email. We appreciate your patience as we continue to serve the public during this
challenging time.

From: James Innes [mailto:[e-mail]]
Sent: Tuesday, June 15, 2021 3:36 PM
To: McCoy, Suzanne <[e-mail]>
Subject: Re: [External] electronic reporting
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Should the forms be blank? Am I supposed to print them, fill them out and mail them in?
On Tue, Jun 15, 2021 at 3:32 PM James Innes <[e-mail]> wrote:
These instructions are not on the letter we received, but I will follow the link you sent.
deg.nc.gov/SW, cleg.nc.gov/SW-eDMR, deg.nc.gov/SW-ePayments and deg.nc.gov/SW-industrial are the only links in
our letter and none of them work.
On Tue, Jun 15, 2021 at 2:55 PM McCoy, Suzanne <[e-mail]> wrote:
Good afternoon James.
Have you completed Steps 1 and 2 of the Registration process?
I need to manually enter user Ids into the system before you can access the site.
Suzanne McCoy
Stormwater Program Administrative Specialist
Division of Energy, Mineral and Land Resources
North Carolina Department of Environmental Quality
Physical: 512 N. Salisbury Street, Office 640K, Raleigh, NC 27604
Mailing: 1612 Mail Service Center, Raleigh, NC 27699-1612
Email: Suzanne. mccoyCa�ncdenr.gov
Phone: [phone]
3

Website: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
E
pppnrin rwmpnial q�a11Yy
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Before printing this email, please consider your budget and the environment.
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely
or are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access
to appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to
handle your requests by phone or email. We appreciate your patience as we continue to serve the public during this
challenging time.
From: James Innes [mailto:[e-mail]]
Sent: Tuesday, June 15, 2021 2:16 PM
To: Lucas, Annette <[e-mail]>; McCoy, Suzanne <[e-mail]>
Cc: inneslaw <[e-mail]>
Subject: [External] electronic reporting
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment
to Report Spam.
I have attempted several times to go through the steps laid out in the notification we received about our
stormwater permit, however, I receive an error message saying the site cannot be reached each time. Is the site up
and running or do I need to wait until July 1st for access?
Thank you.
I

Amy J. I nnes
Innes & Innes, PLLC
1371 Caratoke Hwy.
Moyock NC 27958
Ph: 252-435-6000
Fx: 252-435-6205
Covid 19 Precautions:
We currently operate normal business hours. If you or a family member is sick or has symptoms, please call
us beforehand to re -schedule your closing. You are welcome to bring your own ball point pen to closing. The
conference room table and pens are being wiped down regularly with sanitary wipes. In an effort to be as safe as
possible, we suggest that those whose signatures are not necessary at closings consider avoiding coming in to our
office for the closing.
BEFORE SENDING ANY WIRE, CALL OUR OFFICE AT [phone] TO VERIFY THE INSTRUCTIONS. WE WILL NOT
CHANGE WIRING INSTRUCTIONS. IF YOU RECEIVE WIRING INSTRUCTIONS FOR A DIFFERENT BANK, BRANCH
LOCATION, ACCOUNT NAME OR ACCOUNT NUMBER, THEY SHOULD BE PRESUMED FRAUDULENT. DO NOT SEND
ANY FUNDS AND CONTACT OUR OFFICE IMMEDIATELY.
FAILURE TO FOLLOW THIS PROCEDURE ENDANGERS YOUR FUNDS.
This message may be sent by the law firm of Innes & Innes, PLLC. It is not intended to & nor does it create an
attorney -client relationship or provide any legal advice. This message is intended solely for the named recipient(s)
& if received in error, should be disregarded & discarded. This message may be protected by a legal privilege & is
confidential. Unauthorized interception is prohibited by Federal law.
Innes & Innes, PLLC
1371 Caratoke Hwy.
Moyock NC 27958
Ph: 252-435-6000
Fx: 252-435-6205
5

Covid 19 Precautions:
We currently operate normal business hours. If you or a family member is sick or has symptoms, please callus
beforehand to re -schedule your closing. You are welcome to bring your own ball point pen to closing. The
conference room table and pens are being wiped down regularly with sanitary wipes. In an effort to be as safe as
possible, we suggest that those whose signatures are not necessary at closings consider avoiding coming in to our
office for the closing.
BEFORE SENDING ANY WIRE, CALL OUR OFFICE AT [phone] TO VERIFY THE INSTRUCTIONS. WE WILL NOT
CHANGE WIRING INSTRUCTIONS. IF YOU RECEIVE WIRING INSTRUCTIONS FOR A DIFFERENT BANK, BRANCH
LOCATION, ACCOUNT NAME OR ACCOUNT NUMBER, THEY SHOULD BE PRESUMED FRAUDULENT. DO NOT SEND
ANY FUNDS AND CONTACT OUR OFFICE IMMEDIATELY.
FAILURE TO FOLLOW THIS PROCEDURE ENDANGERS YOUR FUNDS.
This message may be sent by the law firm of Innes & Innes, PLLC. It is not intended to & nor does it create an
attorney -client relationship or provide any legal advice. This message is intended solely for the named recipient(s) &
if received in error, should be disregarded & discarded. This message may be protected by a legal privilege & is
confidential. Unauthorized interception is prohibited by Federal law.
Innes & Innes, PLLC
1371 Caratoke Hwy.
Moyock NC 27958
Ph: 252-435-6000
Fx: 252-435-6205
Covid 19 Precautions:
We currently operate normal business hours. If you or a family member is sick or has symptoms, please callus
beforehand to re -schedule your closing. You are welcome to bring your own ball point pen to closing. The
conference room table and pens are being wiped down regularly with sanitary wipes. In an effort to be as safe as
possible, we suggest that those whose signatures are not necessary at closings consider avoiding coming in to our
office for the closing.
BEFORE SENDING ANY WIRE, CALL OUR OFFICE AT [phone] TO VERIFY THE INSTRUCTIONS. WE WILL NOT
CHANGE WIRING INSTRUCTIONS. IF YOU RECEIVE WIRING INSTRUCTIONS FOR A DIFFERENT BANK, BRANCH

LOCATION, ACCOUNT NAME OR ACCOUNT NUMBER, THEY SHOULD BE PRESUMED FRAUDULENT. DO NOT SEND
ANY FUNDS AND CONTACT OUR OFFICE IMMEDIATELY.
I FAILURE TO FOLLOW THIS PROCEDURE ENDANGERS YOUR FUNDS.
This message may be sent by the law firm of Innes & Innes, PLLC. It is not intended to & nor does it create an
attorney -client relationship or provide any legal advice. This message is intended solely for the named recipient(s) & if
received in error, should be disregarded & discarded. This message may be protected by a legal privilege & is
confidential. Unauthorized interception is prohibited by Federal law.
Innes & Innes, PLLC
1371 Caratoke Hwy.
Moyock NC 27958
Ph: 252-435-6000
Fx: 252-435-6205
Covid 19 Precautions:
We currently operate normal business hours. If you or a family member is sick or has symptoms, please callus
beforehand to re -schedule your closing. You are welcome to bring your own ball point pen to closing. The
conference room table and pens are being wiped down regularly with sanitary wipes. In an effort to be as safe as
possible, we suggest that those whose signatures are not necessary at closings consider avoiding coming in to our
office for the closing.
BEFORE SENDING ANY WIRE, CALL OUR OFFICE AT [phone] TO VERIFY THE INSTRUCTIONS. WE WILL NOT
CHANGE WIRING INSTRUCTIONS. IF YOU RECEIVE WIRING INSTRUCTIONS FOR A DIFFERENT BANK, BRANCH
LOCATION, ACCOUNT NAME OR ACCOUNT NUMBER, THEY SHOULD BE PRESUMED FRAUDULENT. DO NOT SEND ANY
FUNDS AND CONTACT OUR OFFICE IMMEDIATELY.
FAILURE TO FOLLOW THIS PROCEDURE ENDANGERS YOUR FUNDS.
This message may be sent by the law firm of Innes & Innes, PLLC. It is not intended to & nor does it create an attorney -
client relationship or provide any legal advice. This message is intended solely for the named recipient(s) & if received
in error, should be disregarded & discarded. This message may be protected by a legal privilege & is
confidential. Unauthorized interception is prohibited by Federal law.
Innes & Innes, PLLC
1371 Caratoke Hwy.
Moyock NC 27958
Ph: 252-435-6000
Fx: 252-435-6205

Covid 19 Precautions:
We currently operate normal business hours. If you or a family member is sick or has symptoms, please callus
beforehand to re -schedule your closing. You are welcome to bring your own ball point pen to closing. The conference
room table and pens are being wiped down regularly with sanitary wipes. In an effort to be as safe as possible, we
suggest that those whose signatures are not necessary at closings consider avoiding coming in to our office for the
closing.
BEFORE SENDING ANY WIRE, CALL OUR OFFICE AT [phone] TO VERIFY THE INSTRUCTIONS. WE WILL NOT
CHANGE WIRING INSTRUCTIONS. IF YOU RECEIVE WIRING INSTRUCTIONS FOR A DIFFERENT BANK, BRANCH
LOCATION, ACCOUNT NAME OR ACCOUNT NUMBER, THEY SHOULD BE PRESUMED FRAUDULENT. DO NOT SEND ANY
FUNDS AND CONTACT OUR OFFICE IMMEDIATELY.
FAILURE TO FOLLOW THIS PROCEDURE ENDANGERS YOUR FUNDS.
This message may be sent by the law firm of Innes & Innes, PLLC. It is not intended to & nor does it create an attorney -
client relationship or provide any legal advice. This message is intended solely for the named recipient(s) & if received in
error, should be disregarded & discarded. This message may be protected by a legal privilege & is
confidential. Unauthorized interception is prohibited by Federal law.

eDMR Owner Verification Report
Permit No.: Version: Permt Status:
Owner/Permittee : r6( �c f
I
Owner/Permittee Myles
Address: 1 7 I C'.a.f 40 Ve IfWjI I) JO IV & A7 qSJ
Responsible Official:
Resp. Official Title: � +
Facility Name: 6,�eskfcAe Aeadows A Me -
Facility Address: M)o 6 aA a�i�
Registered for eDMR? :
i
I
Page # : 1
Date : 6/15/2021

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Summary
NC DEMLR has the following information in our Permit Database for your permit as of 6/15/2021.
Permit Number: C Permit Status:
Permit Type:
FacilityName:(A
FacilityAddressl:
Facility Address2:
City, State & Zip:��
Owner Information Details:
. ,MUST submit a,Change o , , time tuners �p orm to DEMLRto ma any c anges to t is OwnerJn ornation�
(C/ock:Here'for.. "Change of Name/017rnershin Farm) u r
. e
Owner Name: yhe-!�
Owner Type: Owner Type Group:
Owner Affiliation: Title:
Addressl: 13'71 Ca f +q its i`e H
Address2:
City, State & Zip: b�' 4��{ ��� /VC 2L"79s %3�
Work Phone: 435- 66)w Fax: 615 �.
Email Address: 6✓ eW jv'�Gtj �.
�z,f **:Permit Annual Fee`Bitlm9>**.;,.
�<ywu wt
6/15/2021
A
cav�� ,his
I}
t j
Page 1

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Summary
NC DEMLR has the following information in our Permit Database for vour hermit as of 6/15/2021.
erson(s) with Delegated Signatory Authority
Ja ol- Axj
sons) with Electron�c,5ignature Authority Per
Ff F {
;Outfalls
6/15/2021 Page 2

5TATV. i
NC Department of Environmental Quality
x
' Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmrntal Quality
Stormwater eReporting Registration Form
Directions are in red.
Completion of the Stormwater Electronic Reporting (eReporting) Registration Form is a required
step for the Owner and, if applicable, Facility Administrator(s) to obtain the privilege of
submitting electronic reports to DEQ and in lieu of submitting paper reports.
In addition, this form allows for Owners to designate Responsible Officials and Facility
Administrators who can act on their behalf. Responsible Officials and Facility Administrators
must agree to the Electronic Signature Agreement (ESA) Conditions contained in this form.
A. Owner Information
The Owner is the legal entity to which/whom a permit has been issued. The Owner may be an
individual or organization. Every Owner is required to have a Responsible Official who meets
the legal signature authority requirements in 40 CFR 122.22.
• For a corporation, this individual shall 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, this individual shall be a general partner or the proprietor,
respectively; or i
• For a municipality, State, Federal, or other public agency, this individual shall be either a principal
executive officer or ranking elected official.
Owner Name:
�iyl�shh.�?g
Responsible Official Name:
Title:
Does the Responsible Official
already have an eDIVIR account?
❑Yes 2 �V o
If Yes,
User ID:
Email Address:
1171Ie.5- ) 41n7 rnti, COM
Phone:
�t3A 1.354&150
Mailing Address:
13 71 641^af& �c
City:
b Cj��-` State:
N6-
Zip:
Stormwater Electronic Reporting Registration Form
Page 1

B. Permit Information
=> Include all stormwater permit currently held by the Owner (both Individual and General permits).
Designate any applicable Facility Administrators for each permit. Attach additional pages if you ;
need more space.
i
Permit No.
Facility
Facility°Administrato'r(s)
PPIivable
P
Jd P
DW
0(3 SLN-Aryea
AIC J�? 15-6
Stormwater Electronic Reporting Registration Form
Page 2

C. Facility Administrator Information j
I
=> Include the following information for all Facility Administrators listed in Part B. Attach additional '
pages if you need more space.
Facility Administrator for
Permit Number:
Name:
Title:
Do you already have an eDMR
account?
❑Yes ❑NO
If Yes,
User ID:
Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Facility Administrator for
Permit Number:
Name:
Title:
Do you already have an eDMR
account?
❑Yes ❑NO
If Yes,
User ID:
Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Facility Administrator for
Permit Number:
Name:
Title:
Do you already have an eDMR
account?
❑Yes NO
❑
If Yes,
User ID:
Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
zip.
Facility Administrator for
Permit Number:
Name:
Title:
Do you already have an eDMR
account?
❑Yes ❑ NO
If Yes,
User ID:
Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
zip:
Facility Administrator for
Permit Number:
Name:'
Title:
Do you already have an eDMR
account?
❑Yes ❑NO
If Yes,
User ID:
Organization:
Email Address:
Phone:
Mailing Address:
City:
Stater
zip:
' I
Stormwater Electronic Reporting Registration Form
Page 3

D. Electronic Signature Agreement Conditions
To receive and accept the required electronic signature credential, consisting of a User ID and
password, issued by the North Carolina Department of Environmental Quality (NCDEQ) in order
to sign electronic documents submitted to NCDEQ's Electronic Document Systems and to
receive electronic documents from NCDEQ's systems;
The Responsible Official and Submitter(s) (if applicable) named in this form do herby:
1. Understand that this Electronic Signature Agreement requires me to submit electronic
documents to NCDEQ's approved eDMR system under the authorized program in lieu of paper
submissions.
1:
2. Understand that this Electronic Signature Agreement requires me to accept electronic
transmissions, in lieu of paper transmissions of all permits, permit modifications, authorizations
to construct, and any other correspondence related to reviewing and processing permits from
NCDEQ. This authorization will not become effective until NCDEQ establishes a system for
processing electronic documents; I am notified in writing from NCDEQ that use of the electronic
systems has officially been initiated; and North Carolina rules and statutes are changed to allow
the implementation of electronic submittal and acceptance of documents.
3. Understand that this Electronic Signature Agreement requires me to submit electronic all
necessary information for processing of NPDES application including information for renewal of
existing permits, modification to existing permits, and applications for new discharge permits.
The submittals may include all necessary applications and supporting documentation to
NCDEQ's approved system for electronic submittals in lieu of paper submissions. This
authorization will not become effective until NCDEQ establishes a system for processing
electronic documents; I am notified in writing from NCDEQ that use of the electronic systems
has officially been initiated; and North Carolina rules and statutes are changed to allow the
implementation of electronic submittal and acceptance of documents.
4. Understand that this Electronic Signature Agreement requires me to accept electronic
submissions, in lieu of paper submissions, of all Notices of Deficiency, Notices of Violation, Civil
Penalty Assessments, and any other correspondence related to compliance with federal and
state water quality laws and regulations that might be sent by NCDEQ. This authorization will
not become effective until NCDEQ establishes a system for processing electronic documents; I
am notified in writing from NCDEQ that use of the electronic systems has officially been
initiated; and North Carolina rules and statutes are changed to allow the implementation of
electronic submittal and acceptance of documents. 1I
5. Agree to protect both the electronic signature credential, consisting of my User ID and I'
password, and security questions and answers, from compromise and from use by anyone
except me. Specifically, I agree to maintain the secrecy of my electronic signature credential
and security questions and answers; I will not divulge or delegate my credential or security
questions and answers to any other individual; I will not store my credential or security
questions and answers in an unprotected location; and I will not allow my electronic signature
credential or security questions and answers to be written into computer scripts to achieve
automated log -in.
6. Understand and agree that I will be held as legally bound, obligated, and responsible for the use
of my electronic signature as I would be using my hand-written signature.
7. Understand that I will be informed through my registered email address whenever my User ID
or password has been modified.
Stormwater Electronic Reporting Registration Form
Page 4 �'

8. Understand that eDMR reports the last date my User ID and password were used immediately
after successfully logging into eDMR.
9. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMR(c-)_ncdenr.gov as
soon as possible, but no later than 24 hours, after suspecting or determining that my User ID
and/or password have become lost, stolen or otherwise compromised.
10. Agree that I will review the contents of all electronic submissions prior to submission
11. Understand that I will automatically receive an email receipt at my registered email address
from the NCDEQ's SW-eDMR system for any submission that contains a valid electronic
signature, identifying the document received, the signatory, and the date and time of receipt.
12. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMR(c)-ncdenr.gov if I'
do not receive an email receipt as specified above within five (5) business days for any
electronically signed submission using my credentials.
13. Agree that if I received an email notification for an activity that I do not believe that I performed,
I will notify the NCDDEQ SW-eDMR Administrator via email at SW-eDMR(a-)_ncdenr.gov as soon
as possible, but no later than 24 hours, after receipt.
14. Agree to report, within 24 hours of discovery, any evidence of discrepancy between any
electronic document I have signed and submitted and what the NCDEQ eDMR has received
from me by contacting the NCDEQ SW-eDMR Administrator via email at SW-
eDMR(a-)-ncdenr.gov.
15. Understand that the NCDEQ eDMR's system will automatically reject any electronic document
submitted without a valid electronic signature if such signature is required. J
16. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMRna.ncdenr.gov
within ten working days if my duties change and I no longer need to interact with eDMR on
behalf of my organization.
17. Agree to notify the NCDEQ SW-eDMR Administrator via email at SW-eDMR[7a ncdenr.gov if I
cease to represent the regulated entity specified above as signatory of that organization's I
electronic submissions as soon as this change in relationship occurs.
18. Understand that the NCDEQ may contact the Organization's Responsible Official, who signs
below to authorize me as a signatory for the Owner/Organization, in order to verify my identity.
19. Agree to retain a copy of this signed agreement as long as I continue to represent the regulated
entity specified above as signatory of the Organization's electronic submissions.
20. Certify that I have the authority to enter into this Agreement on behalf of the Organization
identified above, and I am a signatory authorized to represent that Organization, and I am able
to sign and submit reports and other information on behalf of that Organization in the capacity
required by statute and/or regulation. "
Stormwater Electronic Reporting Registration Form
Page 5

E. 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.
I, _ _UI.Frs�i�le5 (printed name), have the authority to enter into j
--� � I
this Agreement for c /t we-s zllole,5 (Owner/Organization Name).
I request the NCDEQ grant me and, if included in Part B of this form, the named Facility
Administrator(s), an electronic signature credential to submit and accept documents
electronically on behalf of my organization.
I acknowledge that I, and if included in Part B of this form, the named Facility Administrator(s),
work at/for my organization and have authority to submit and accept electronic documents and
act as a signatory for purposes of the NCDEQ's electronic document systems.
By submitting this application, I, �n!s Zti (printed name),
have read, understand, and accept the terms and conditions of this Electronic Signature
Agreement. I certify under penalty of law that I have personally examined and am familiar with
the information submitted in this application and all attachments and that, based on my inquiry
of those persons immediately responsible for obtaining the information contained in the
application, I believe that the information is true, accurate and complete. I am aware that there
are significant penalties for submitting false information, including the possibility of fine and
imprisonment.
Re nsible%Official Signature
Email Address
6%ti-119.-
Title
2sa L657KQ0r->
Phone Number
Stormwater Electronic Reporting Registration Form
Page 6
6 lS7 aI
Date
eDMR User ID

I�
u '
F. Facility Administrator Signature
=> Provide a separate page for every Facility Administrator listed in Part B.
r
Facility Administrators are users other than the Responsible Official who can submit this
agreement to request to sign reports electronically and other information and to accept
electronic documents.
I, (printed name), am authorized by the Responsible
Official named in this document, who has the authority under the applicable standards, to enter
into this agreement for (Owner/Organization Name).
By submitting this application, I, (printed name),
have read, understand, and accept the terms and conditions of this Electronic Signature
Agreement. I certify under penalty of law that I have personally examined and am familiar with
the information submitted in this application and all attachments and that, based on my inquiry
of those persons immediately responsible for obtaining the information contained in the
application, I believe that the information is true, accurate and complete. I am aware that there
are significant penalties for submitting false information, including the possibility of fine and
imprisonment.
Submitter Signature
Email Address
Title
Phone Number
Date
eDMR User ID III
i
Stormwater Electronic Reporting Registration Form
Page 7
i