NC0023949_Electronic Signature Agreement_20220713

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
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

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 eDMRad.minLaincdenr.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 e.DMRadmin(ii).ncdenr. ov 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 eDMRadmin@ncdenr.g 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
Submitter' (if applicable)
NCO023949
Goldsboro WRF
714 Arrington Bridge Road
Justin Bauer
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: httl�s://deu.nc.00v/about/divisions/water-
resources/cdmr/forms-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

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.
L?:10IU- "( (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 iu jGQrv
(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.
(WP-F) 71-ul�i /3 , . 202Z.
Su itter Signature Title Date-
�bGtte� goicYSl�on�nc.c�oa/ q►� --735- 33ag
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 J2)6 day of 1 20 ZZ .
JENNIFER PROCTOR
Notary Public
Johnston County
North Carolina
(SEAL)
Si a re of .. tary Public
1--T(o
Printed Name of Notary Public
My Commission Expires: 2
NCDWR Electronic Submittal Agreement Version 1 Page 5