NC0056731_Owner (Name Change)_20210507

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Water Resources
ENVIRONMENTAL QUALITY
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Interim Director
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCOO 5 /6 / 7 / 3 / 1 or NCG5 / / / /
1. Facility Name: Grande Oaks Subdivision WWTP
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
b. Name change only
X c. Other (please explain): Change in responsible official only
2. New owner's name (name to be put on permit):
3. New owner's or signing official's name and title: Michael J. Myers
(Person legally responsible for permit)
President
(Title)
4. Mailing address: 4700 Homewood Court, Suite 108 City: Raleigh
State: NC
Zip Code: 27609 Phone: ( 252 ) 235-4900
E-mail address: mmyers ae;�7envirolinkinc.com
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh, NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deq.nc. gov/aboubdivisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
I, Michael J. Myers , attest that this application for a
name/ownership change has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this application are not completed and that
if all required supporting information and attachments are not included, this application
package will be returned as incomplete.
Signature: 777' "�
Date: 5-5-2021
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 11/2017

Water Resources
ERVINONH EI IA L auAu7Y
State of North Carolina
Department of Environmental Quality
Division of Water Resources
EDMR REGISTRATION FORM
INSTRUCTIONS AND SUPPORTING DOCUMENTATION
This form is used to register NPDES wastewater permittees to use NCDWR's eDMR system for the purpose of
electronically submitting required monthly monitoring reports.
For more information on the eDMR system, visit the Division of Water Resources' eDMR website.
General — When submitting an application to the NCDWR's Information Processing Unit, please use the following
instructions as a checklist to ensure all required items are submitted. Adherence to these instructions and
checking the provided boxes will help produce a quicker review time and reduce the amount of requested
additional information.
I. eDMR Registration Application [FORM: NC eDMR Registration Form (Revision 4.1)]:
❑ Submit the completed and appropriately executed eDMR registration application form [FORM: NC eDMR
Registration Form (Revision 4.1)].
❑ Part A: Permit/Facility Information. Provide a permit number and the associated facility
information. Only a single permit number is needed for registration. If the Owner holds
multiple NPDES wastewater permits, then the permit number provided on the application will
be used to identify the Owner and all associated permits. All permits issued to the Owner will
be automatically registered for eDMR. NOTE: Owner is also known as the Permittee and may
be an individual or organization.
El Part B: Owner User Information. Provide the Owner/Responsible Official information that will
be used to create the Facility Owner in eDMR. The Owner is the legal entity to which the
permit(s) have been issued and may be an individual or organization. For an organization,
the information provided for the Owner should be the designated Responsible Official or the
person with delegated signatory authority for the Owner as specified in Part II, Section B.11
of the Standard Conditions for NPDES Permits and 40 CFR 122.22.
❑ Part C: User Account Information. Provide the user details for each individual who will be
assigned Facility Administrators permission and/or Submitters permission.
1. Facility Administrator Permission. The Facility Administrator is the person
responsible for managing user information for the facility/permit. The Facility
Administrator user permission can be assigned by the Owner or can be assigned at
the time of registration by the NCDWR eDMR Administrator. If someone other than
the Owner will be responsible for managing facility users within eDMR and you would
like NCDWR to set up the permission at the time of registration, then provide the
user details for the individual who will need the user permission. Note: If this person
will be responsible for submitting eDMR reports, then you will also need to request
Submitter permission for this user.
2. Submitter Permission. The Submitter is the person who submits the electronic
report. This person may be the Owner or other delegated person that has signatory
authority for the permit. The Submitter user permission can only be assigned by the
NCDWR eDMR Administrator. The Owner specified within the application will be
given full eDMR permissions including Submitter user permission.
NC eDMR Registration Form (Revision 4.1) Instructions i

The Submitter is equivalent to the individual who signs the certification statement on
the back of the Discharge Monitoring Report. In most cases, the Submitter will be the
Owner but may be other delegated individuals. The Submitter must be an individual
with delegated signatory authority. If individuals other than the duly authorized
person for the Owner have been delegated signatory authority, the Division of Water
Resources must be notified in writing of such delegations as specified in the signatory
requirements in Part II, Section B.11 of the Standard Conditions for NPDES Permits
and 40 CFR 122.22. A delegation of authority form is available from the eDMR
website.
❑ Responsible Official Authorization. Complete the Responsible Official Authorization and
identify the individual duly authorized to sign applications or reports for the Owner.
❑ Registration Certification. Complete and sign the Registration Certification in accordance with
Part II, Section B.11 of the Standard Conditions for NPDES Permits and 40 CFR 122.22. An
alternate person may be designated as the responsible official if written authorization (see
paragraph III below) is provided from a person who meets the criteria in Part II, Section B.11
of the Standard Conditions for NPDES Permits and 40 CFR 122.22.
II. eDMR Owner Verification Report:
❑ Submit the eDMR Owner Verification Report verifying the facility permit information. Should the Owner
name, Facility information, or ORC Designation be incorrect, the Owner must notify the appropriate
NCDWR contact to resolve any discrepancies before continuing with the registration process. The report
is accessed using the Registration Verification link located on the eDMR User Registration web page. The
permit information related to all NPDES wastewater permits issued to the Owner will be returned in a
PDF report format. If the Owner has multiple NPDES permits, the Owner should verify that all permits are
returned in the report. If there are permits missing from the report, the Owner should conduct a search
for each missing permit and verify the Owner Name. Any discrepancies detected must be resolved before
registration.
III. Delegation of Signature Authority:
❑ Complete and submit the Delegation of Signature Authority form (located on the eDMR Forms and
Reports web page) for each individual who has been authorized, as described in paragraph I above, to
sign reports for the Owner. This includes each individual who will be given Submitters permission. If a
delegation letter has been previously submitted to NCDWR, then include a copy with your application
package.
THE COMPLETED REGISTRATION FORM AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO THE
NORTH CAROLINA DIVISION OF WATER RESOURCES
Fax:
or Email: or US Postal Mail:
[phone] [e-mail] Information Processing Unit
Attn: eDMR Registration
1617 Mail Service Center
Raleigh, NC 27699-1617
NC eDMR Registration Form (Revision 4.1) Instructions ii

Wale! Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
EDMR REGISTRATION FORM
Part A. PERMIT/FACILITY INFORMATION
1. NPDES Permit Number: N 1 C 1 O 1 O 1 5 I6 17 13 El I
2. Owner/Organization Name:
3. Facility Name: Grande Oaks Subdivision WWTP
4. Facility's Physical Address: Red Coach Road
ri Durham
Part B. OWNER USER INFORMATION
State: NC
Zip Code: 27705
1. Responsible Official's Name: Michael J. Myers Title: President
(Owner or duly authorized representative)
2. Mailing Address: 4700 Homewood Court, Suite 108
City: Raleigh State: NC Zip Code: 27609
3. Telephone Number: 252-235-4900
4. Email Address: [e-mail]
5. User ID (Assigned by NCDWR eDMR Administrator): [e-mail]
Part C. USER ACCOUNT INFORMATION
1. Facility Administrator Permission
The Facility Administrator user permission can be assigned at the time of registration by the NCDWR
eDMR Administrator. If someone other than the Owner will be responsible for managing facility users
within eDMR and you would like the Division to set up the permission at the time of registration, then
please provide the user details for the individual who will need the Facility Administrator user permission.
Note: If this person will be responsible for submitting eDMR reports, then you will also need to request
Submitter permission for this user.
In addition to the user details, please specify the permit number(s) to which the user will be associated. If
additional space is needed, please make additional copies of the Facility Administrator User Details and
complete as needed.
Facility Administrator User Details
Permit No. (s): NC0056731
First Name:
Middle Name:
Rebecca
Lorene
Last Name:
Manning
Phone Number:
984-365-9155
Email:
[e-mail]
User ID:
(Assigned by DWR eDMR Administrator)
NC eDMR Registration Form (Revision 4.1) 1

2. Submitter Permission
Provide the users, in addition to the Owner, who will need Submitter permission. The Submitter user
permission can only be assigned by the NCDWR eDMR Administrator. The Owner specified above will be
given full eDMR permissions including Submitter permission.
In addition to the user details, please specify the permit(s) to which each user will be associated for eDMR
submittal. Should additional space be needed for users and/or permits, please make additional copies of
this page and complete as needed.
NOTE: The Owner will be responsible for creating all facility users except those with Submitter permissions.
In addition to the Owner and Submitter user groups, there are four user types identified by user
permission level: Facility Administrator, Certifier, Data Entry and View Only.
The Owner and Facility Administrator will have the ability to create and manage facility users. The
Facility User Management Guide, located on the eDMR User Documentation web page, provides the
appropriate procedures for facility user management.
Submitter User Details
Permit No. (s):
NC0056731
First Name:
Rebecca
Middle Name:
Lorene
Last Name:
Manning
984-365-9155
Phone Number:
Email:
[e-mail]
User ID:
(Assigned byDWR eDMR Administrator)
Submitter User Details
Permit No. (s):
First Name:
Middle Name:
Last Name:
Phone Number:
Email:
User ID:
(Assigned by DWR eDMR Administrator)
NC eDMR Registration Form (Revision 4.1) 2

RESPONSIBLE OFFICIAL AUTHORIZATION
The Responsible Official, as identified in accordance with Part II, Section B.11 of the Standard Conditions for
NPDES Permits and 40 CFR 122.22, is the appropriate individual with the authority to sign applications or reports
for the Owner/Organization.
1, Michael J. Myers (printed name), have the authority to make this request for
Grande Oaks Subdivision WWTP (Owner/Organization Name).
REGISTRATION CERTIFICATION
For the permit(s) associated with the Owner identified above, I request permission to submit DMR data using the
NCDWR eDMR system.
I understand that electronic submittal of the DMR does not fully satisfy US EPA's electronic signature
requirements and as a result, I understand I will be required to print, sign, and submit hardcopies (one signed
original and a copy) of the eDMR to NCDWR under the same reporting requirements as paper -based DMRs as
specified in Part II, Condition D (2) of the NPDES Permit.
I agree to protect the security of my user ID and password from compromise and shall take all necessary steps to
prevent its loss, disclosure, modification, or unauthorized use.
Michael J. Myers President
Owner/ResponsbI
Owner/Responsi
fficial Name (type or print)
Official Signature
North Carolina General Statute § 143-215.6E provides that:
Official Title (type or print)
5-5-2021
Date
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; or who
knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who
falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be
operated or maintained under this Article or rules of the Commission implementing this Article, shall be guilty of a Class 2
misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000). 18 U.S.C. Section 1001 provides a
punishment by a fine or imprisonment not more than 5 years, or both, for a similar offense.
NC eDMR Registration Form (Revision 4.1) 3

N.C. Department of Environmental Quality
Division of Water Resources
Electronic Signature Agreement
Instructions and Submittal Form
This form is used to request that the N. C. Division of Water Resources (NCDWR) grant electronic
signature credentials to the individuals outlined in the form for NPDES wastewater permittees. The
Electronic Signature Agreement (ESA) must be submitted in hard copy form with original notarized
signatures for each individual requesting the credentials. For the most recent version of this form
please check NCDWR's website at: https://deg.nc.gov/about/divisions/water-resourcesJedmr/forms-and-reports
Please use the following instructions as a checklist to ensure that all required information is included.
Following these instructions will help provide a quicker review time and reduce the need for additional
information requests.
❑ Section A. Owner / Organization Information
- Provide the Owner / Organization information requested. The Owner is the legal entity to which
permits have been issued and may be an individual or organization.
- This section requires a Responsible Official. For an organization the information provided
should be the person with legal signature authority in accordance with 40 CFR 122.22.
- This section requires an email address for the responsible official. Email will be the primary
contact method so you must assure that any changes or updates to email addresses are
provided to NCDWR in a timely manner.
D Section B. Agreement Conditions
- Please read these conditions carefully as they outline the terms of the electronic submittal
credentials.
❑ Section C. Permit/Facility Information
- Provide information on the facilities and wastewater NPDES permits associated with the Owner/
Organization indicated in Section A of the form. If you need more space a supplemental page
that may be used and attached is available on our eDMR website at:
http s://deco. n c.gov/about/d ivi sio n sJwater-resources/ed m rlfo rm s-and-reports
- If there will be a document submitter other than the responsible official, then please indicate
the individual's name in this section in the last Column.
❑ Section D. Responsible Official Signature
- Provide the information, signature and notarization for the responsible official as designated
throughout the form.
- You must return this section with original signatures, copies will not be accepted.
- A responsible official will be granted electronic submittal credentials even if other submitters
are included in the form.
❑ Section E. Submitter Signature
If you are only requesting electronic submittal credentials for the responsible official, then you
do not need to complete Section E.
Instructions Page i

- If you are requesting electronic submittal credentials for one or more individuals other than the
responsible official, then those individuals must be included in Section C with the
permits/facilities they will have electronic responsibilities for.
- NCDWR must be notified in writing of delegations of signature authority. If you are providing
information for a Submitter that does not already have documentation of this authority on file
with the NCDWR then you may be asked to provide this documentation
- You must include the Section E Submitter Signature page for each submitter listed in Section C.
- Provide the information, signature and notarization for the submitter as designated.
You must return this section with original signatures, copies will not be accepted.
❑ Questions
- If you have any questions about the NCDWR ESA submittal process, please contact us at:
- Phone: [phone]
- Email: eDMRadminPncdenr.gov
❑ SUBMIT COMPLETED FORM TO:
Information Processing Unit
Attn: Electronic Signature Agreements
1617 Mail Service Center
Raleigh, NC 27699-1617
Instructions Page ii

N.C. Department of Environmental Quality
Division of Water Resources
Electronic Signature Agreement
Federal regulations require that electronic documents must have valid electronic signatures if Title 40 of
the Code of Federal Regulations requires handwritten signatures on the paper documents they replace.
Valid electronic signature refers to an electronic signature on an electronic document that has been
created with an electronic signature credential.
This Electronic Signature Agreement, when finalized and approved, will allow the individuals with
electronic signature credentials to sign electronically a variety of required permit documents in lieu of the
submittal of signed paper copies. The submittal of Electronic Discharge Monitoring Reports (eDMR)
will be available once your electronic signature credentials are in place. Some agreements for document
submittals or acceptance, as noted in the Agreement Conditions (Section B.), are not currently available
electronically but are included here to have the agreements in place and to avoid the need to complete
future submittal of agreement forms when these systems are initiated.
A. Owner / Organization Information
Owner/Organization Name:
Grande Oaks Subdivision VWVfP
Responsible Official:
(as identified in accordance with 40 CFR 122.22)
Michael J. Myers
Street Address:
4700 Homewood Court, #108
City:
Raleigh
State / Zip:
North Carolina 27609
Phone Number:
[phone]
Email Address:
*email will be the primary method of contact for the electronic
submittal process so it is important to have an accurate email
available at all times
[e-mail]
B. Agreement Conditions
To receive and accept the required electronic signature credential, consisting of a user name and
password, issued by the North Carolina Division of Water Resources (NCDWR) in order to sign
electronic documents submitted to NCDWR's Electronic Document Systems and to receive electronic
documents from NCDWR's systems;
The Responsible Official and Submitter (if applicable) named in this form do herby:
1. Understand that this Electronic Signature Agreement requires me to submit electronic documents to
NCDWR's approved eDMR system under the authorized program in lieu of paper submissions.
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 NCDWR. This
authorization will not become effective until NCDWR establishes a system for processing electronic
documents; I am notified in writing from NCDWR 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.
NCDWR Electronic Submittal Agreement Version 1 Page 1

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 NCDWR's approved system
for electronic submittals in lieu of paper submissions. This authorization will not become effective
until NCDWR establishes a system for processing electronic documents; I am notified in writing from
NCDWR 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 violations, Civil Penalty
Assessments, and any other correspondence related to compliance with federal and state water quality
laws and regulations that might be sent by NCDWR. This authorization will not become effective
until NCDWR establishes a system for processing electronic documents; I am notified in writing from
NCDWR 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.
5. Agree to protect both the electronic signature credential, consisting of my user name and 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 name or
password has been modified.
8. Understand that eDMR reports the last date my user name and password were used immediately after
successfully logging into eDMR.
9. Agree to contact the NCDWR eDMR Administrator via email at eDMRadmin u]ncderir.gov as soon
as possible, but no later than 24 hours, after suspecting or determining that my user name 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
NCDWR's 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 NCDWR eDMR Administrator via email at [e-mail] 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 NCDWR eDMR Administrator via email at eDMRadmin@ncdeiir..cr,ov as soon as
possible, but no later than 24 hours, after receipt.
NCDWR Electronic Submittal Agreement Version 1 Page 2

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 NCDWR eDMR has received from me by
contacting the NCDWR eDMR Administrator via email at [e-mail].
nedenr.gov.
15. Understand that the NCDWR eDMR's system will automatically reject any electronic document
submitted without a valid electronic signature if such signature is required.
16. Agree to contact the NCDWR eDMR Administrator via email at eDMRadminancdenr.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 NCDWR eDMR Administrator via email at [e-mail] if I cease
to represent the regulated entity specified above as signatory of that organization's electronic
submissions as soon as this change in relationship occurs.
18. Understand that the NCDWR 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.
C. Permit/Facility Information
Approval under this Electronic Signature Agreement is applicable to the following permits and if
applicable to the Submitters, if noted here and in Section E:
Permit
Number'
Facility Name
Facility Address
Submitter2 (if applicable)
NC0056731
Grande Oaks S/D
Red Coach Drive
Rebecca Manning
1.
You may only include permits associated with One owner. If more space is needed for additional permits or submitters you
may attach separate pages. A supplemental sheet is available at: httns://deq.nc.gov/about/divisions/watur-
re so u ree stedrn rlfa rm s-and-reports
2. A separate Section E must be included for each Submitter in order to obtain a hard copy signature and notarization for all
entities. If more than one individual will have submitter permissions for the same permit, then indicate this on separate
rows.
NCDWR Electronic Submittal Agreement Version 1
Page 3

D. 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, Michael J. Myers (printed name), have the authority to enter into this
Agreement for Grande Oaks Subdivision WWTP (Owner/Organization Name).
I request the NCDWR grant me and, if included in Sections C and E of this form, the named Submitter(s),
an electronic signature credential to submit and accept documents electronically on behalf of my
organization.
I acknowledge that I, and the individual(s) named in Sections C and E (if applicable), work at/for my
organization and have authority to submit and accept electronic documents and act as a signatory for
purposes of the NCDWR's electronic document systems.
By submitting this application, I, Michael J. Myers (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.
'2-
President 6-4-,/
Responsible O icial Signature Title Date
[e-mail]
252-235-4900
Email Address Phone Number
*email will be the primary method of contact for the electronic submittal process so it is important to have an accurate email
available at all times
If you are a current eDMR submitter please provide your User Id: [e-mail]
User Id
Subscribed and sworn to before me this day of m , 20
, BLAN,,y
Notary Public
— Wake
County
P
t�
(SEAL)••r�''�iZ' ►O CAFE Y\`y',�
NCDWR Electronic Submittal Agreement Version 1
ouu,---Ve-owAc,kenL—
Signature of Notary Public
ma.rie,1Lax cf a-rrd
Printed Name of Notary Public
My Commission Expires: 1,0 I , 2-0 a- PN
Page 4

E. Submitter Signature
The Submitter (electronic signature applicant) is a user other than the Responsible Official who submits
this agreement to request to sign reports electronically. The Submitter is given signatory authority by an
individual identified as the Responsible Official by the Owner/Organization to sign reports and other
information and to accept electronic documents.
I, Rebecca Manning (printed name), am authorized by the Responsible Official
name in this document, who does have the authority under the applicable standards, to enter into this
agreement for Grande Oaks Subdivision WA/TP (Owner/Organization Name).
By submitting this application, I, Rebecca Manning (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.
CcAlaf VY
Submitter Signature
•
Compliance Coordinator 6 L 5 /1 0t).
Title Date
[e-mail] 984-365-9155
Email Address Phone Number
*email will be the primary method of contact for the electronic submittal process so it is important to have an accurate email
available at all times
If you are a current eDMR submitter please provide your User Id: [e-mail]
User Id
Subscribed and sworn to before me this �day of Mal 1 , 20 It .
.`tiR���";Ey►B LANi.` 'i, �.
Notary Public
Wake
CountY
,/,CA R �►����..
Signature of Notary Public
hn i - �to.t-,chard
Printed Name of Notary Public
My Commission Expires: 10 a. i, l g-O
NCDWR Electronic Submittal Agreement Version 1 Page 5