NC0025496_Other Agency Documents_20210503

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (g@ EQ/D
wR
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: Ritchie Haynes
Email Address: [e-mail]
Permittee Signature:
Facility Name: Lincolnton
MAY e 3 2021
WOROS
MOORESVILLE FREOfONAL OFFICE
Date:
f/
Permit # NC0025496
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: WW
Facility Grade: IV
ORC
OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Donald Burkey
Certificate Type: WW
Email Address:
Signature:
Certificate Grade: 1V
Work Phone:
Certificate #:
[phone]
13485
Effective Date: L - as - 0 a )
"1 certify that 1 agree to my designation as Operator in Responsible Charge for the facility noted. / understand and will abide by the
rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.'
BACKUP ORC
Print Full Name: Daniel Perry
Certificate Type: WW
Email Address:
Signature:
Certificate Grade: IV
[e-mail]
Work Phone:
Certificate #:
[phone]
1009447
Effective Date:
"1 certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email
ORIGINAL to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Em 'I rtdmit n d'- n .o Fax: [phone]
at ce
Mail or Fax a COPY to: Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville Raleigh
610 E. Center Ave., Suite 301 3800 Barrett Dr.
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 5/2019

Date: April 22, 2021
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
Facility Name: Lincolnton WWTP
NPDES Permit Number: N J C I 0 I 0 1 2 1 5 1 4 1 9 1 6
To Whom It May Concern:
By notice of this letter, 1 hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information relating to the operations at
the subject facility as required by all applicable federal, state, and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 2B.0506.
Individual #1
Individual #2 (f applicable)
Name:
Donald Burkey
Daniel Perry
Title:
ORC
BORC
Mailing Address: '
PO Drawer 617
Lincolnton, NC 28093
PO Drawer 617
Lincolnton, NC 28093
Physical Address:
(ifdiferent) .
608 Hwy 150 Bypass West
Lincolnton, NC 28092
608 Hwy 150 Bypass West
Lincolnton, NC 28092
Email Address:
[e-mail]
[e-mail]
Office Phone:
[phone]
[phone]
Mobile Phone:
If you have any questions regarding this letter, please feel free to contact me at either the phone
number or email address below.
Sincerely,
horized S. ning Official's Signature
Ritchie Haynes
City Manager
Authorized Signing Official's Name (type or print) Title
PO Drawer 617 Lincolnton, NC 28093
Mailing Address
[e-mail]
Email Address
[phone]
Office Phone
cc:
Mooresville
Mobile Phone
Regional Office, Water Quality Permitting Section
(Enter region name)

Submitter Change Request Form — (Add/update users)
North Carolina Electronic Discharge Monitoring Report System
EDMR registered Owners may use this form to add or update eDMR users to the NCDWR's Electronic
Discharge Monitoring Report system. If the Organization is not currently registered for eDMR, then the
Owner or designated Responsible Official will need to complete the required eDMR Registration Form
(available from the eDMR website) and submit it to the NCDWR eDMR Administrator at the address
below.
Typ of Request (please select):
Add Submitter Permissions: (See Section B)
Update Submitter Permissions: (See Section B)
To add or update eDMR user permissions, please provide the following information:
Section A: Owner Information
NPDES Permit Number:
NC0025496
Owner / Organization Name:Lincolnton
WWTP
Responsible Official
(as identified in accordance with 40 CFI?122.22)
Ritchie Haynes
Street Address:
608 Hwy 150 Bypass West
City:
Lincointon
State / Zip Code:
NC 28092
Telephone number:
( 704 ) 736-8980
E-mail address:
[e-mail]
Section B: Activate New Submitter or Update Existing User
Please complete the Submitter User Details on page 2 for the individuals who will need Submitter
permissions or to update Submitter details, such as adding additional permits, to an existing user.
Submitter permissions can only be assigned by the NCDWR eDMR Administrator. Note: The Owner
and Facility Administrator can deactivate or delete eDMR user permissions for any individual within
its organization, including Submitter permissions.
The Submitter is equivalent to the individual who signs the certification statement on the back of the
Discharge Monitoring Report. The Submitter must be an individual with delegated signatory authority
for the Owner/Organization. If individuals other than the Responsible Official for the Owner have been
delegated signatory authority, the Division of Water Resources must be notified in writing of such
delegations. A delegation of authority form is available from the eDMR website.
In addition to the User Details, please specify the NPDES permit(s) that each user will be associated with
for eDMR submittal. Should additional space be needed for users and/or permits, please make additional
copies of the Submitter User Details page and complete as needed.
NCDWR eDMR Submitter Change Request Form - ver. 1.0
Page 1

Submitter User Details
Permit No. (s):
NC0025496
First Name:
Daniel
Middle Name:
Brandon
Last Name:
Perry
Phone Number:
[phone]
Email•
dperrjj©lincoIntonnC.ortj
User ID:
(Assigned by NCDWR eDMR Administrator)
Select Request
Type:
❑ Add User Permission
Add/Update User Permission as of (Date):
0 Update User Permission
Submitter User Details
Permit No. (s):
First Name:
Middle Name:
Last Name:
Phone Number:
( )
Email:
UserID:
(Assigned by NCDWR eDMR Administrator)
Select Request
Type:
0 Add User Permission
Add/Update User Permission as of (Date):
■ Update User Permission
Submitter User Details
Permit No. (s):
First Name:
Middle Name:
Last Name:
Phone Number:
( )
Email:
User ID:
(Assigned by NCDWR eDMR Administrator)
Select Request
Type:
0 Add User Permission
Add/Update User Permission as of (Date):
0 Update User Permission
NCDWR eDMR Submitter Change Request Form - ver. 1.0
Page 2

Responsible Official Authorization
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate individual
with the authority to sign reports for the organization.
I,
Ritchie Haynes
Lincolnton WWTP
(printed name), have the authority to make this request for
(Owner/Organization Name).
I request the NCDWR add or update the eDMR Submitter user permission(s) as indicated above on the
Submitter User Details page.
ner/Responsible Official Signature
C;11 notritle r aa9//
Title— Date
Please return the completed form to the NCDWR eDMR Administrator via:
Fax:
or E-mail: or Mail to:
[phone] eDMRadminnncdenr.gov
Information Processing Unit
Attn: eDMR Registration
1617 Mail Service Center
Raleigh, NC 27699-1617
NCDWR eDMR Submitter Change Request Form - ver. 1.0
Page 3

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 fo avoid the need to complete
future submittal of agreement forms when these systems are initiated.
A. Owner / Organization Information
Own er/Organizatian Name;
Lincolnton WWTP
Responsible Official-
(as identified in accordance with 40 CFR 122.22)
Ritchie Haynes
Street Address;
608 Hwy 150 Bypass West
City:
Lincolnton
State / Zip;
NC 28092
Phone Number:
(704 ) 736-8960
Email Addresst
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 1 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.
$ 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 eDMRadminancdenr.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 eDMRadmin(r ncdenr gm 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 a ncdenr.gov 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 eDMRadinin a.ncdenr.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 eDMRadntin(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 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)
NC0025496
Lincolnton WWTP
608 Hwy 150 Bypass West
Lincolnton, NC 28092
Donald Burkey
NC0025496
Lincolnton WWTP
608 Hwy 150 Bypass West
Lincolnton, NC 28092
Daniel Perry
I You ma 1,
l d
•
y on } me u e permits associated wun One if owner. more space is needed for additional permits or submitters you
may attach separate pages. A supplemental sheet is available at: https://deq.nc,goviabout,divisions/water-
resourceslednir/thrms-andu'more_
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, Ritchie Haynes
this Agreement for (printed name), have the authority to enter into
Lincolnton 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, Ritchie Haynes
have read, understand, and accept the tei ms and conditions of this Electronic Signature Agreement. Irinted e),
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.
sponsible Ocial Signature
City Manager
Title Date
/717.9abi
rhaynes(a�lincolnton.org [phone]
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:
User Id
Subscribed and sworn to before me this s7� "dday of 1, �, 20 02 ( .
®q�°•dTAAi,°9 '• .
1.�.- 41
Signatu e o otary Pu is
pine,.., A. incirarn
Printed Name of Notary Pdblic
My Commission Expires: ..�,�„ jpaNi j 7 4joa?�
NCDWR Electronic Submittal Agreement Version 1
Page 4

E. Submitter Signature
The Submitter (electronic si ature applicant) is a user other than the Responsible Official who submits
this agreement to request to ign 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, Donald Burkey (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 Lincolnton WWTP (Owner/Organization Name).
By submitting this application, I, Donald Burkev (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 th t there are significant penalties for submitting false information, including
the possibility of fine and imprisonment.
Submitter Signature
dburkeyWincolntonnc.o
Email Address
*email will be the primary method
available at all times
If you are a current eDMR su
Subscribed and sworn to before me this
o.0% ONE A �ti.
NO ��
TA '.p
e .
. MyCon- er
r- ; .. a' Fkpirts
2: ,o ,)
i'• Ue L I C',„??5bRi
••
•
ORC
Title
[phone]
4- P9-aoa!
Date
Phone Number
contact for the electronic submittal process so it is important to have an accurate email
mitter please provide your User Id: dburkey(&,lincolntonnc.org
User Id
o'd I'd day of ,4)/d_i , 20 ti%1
Signature of Notary Public
In.tOlne, A. Ii, r4m
Printed Name of Notary Ptiblic
My Commission Expires:
aim �' i.e.�oJ
NCDWR Electronic Submittal Agreement Version 1
Page 5

F. 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.
1, Daniel Perry (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 Lincolnton WWTP (Owner/Organization Name).
By submitting this application, I, Daniel Perry
understand, and accept the terms and conditions of this Electronic Signature Agreement. Iecertify 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 an aware that there are significant penalties for submitting false information, including
the possibility of fine and imprisonment.
Submitter Signature
, /tt.4- C C BORC
44 Title
— Z©zf
Date
dperrvAlincolntonnc.org [phone]
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:
User Id
Subscribed and sworn to before me this "`day of
Signatutfe of Notary Public
20 0/ .
fl Inc r
Printe . Name of Notary Pules
My Commission Expires: v ugrt 07 ��4
a
NCDWR Electronic Submittal Agreement Version 1
Page 6