NC0089052_EDMR Registration Form 2014_20140922

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North Carolina (NC) eDMR Reports
eDMR Reeistration Form
EDMR is an electronic reporting system, which will provide a facility Owner the ability to submit
discharge monitoring reports via the internet. EDMR is only currently available to facilities that
have an NPDES Wastewater permit issued by the Division of Water Resources. Registration for
eDMR must be completed by the legal Owner of the facility(s), and this legal Owner must be the
same Owner to which the permit(s) have been issued. Once an Owner is registered for eDMR, all
permits held by the Owner will also be registered and able to submit reports via eDMR.
NOTE: Before completing and submitting the registration form, the legal Owners as specified
above should verify the permit facility, Owner, and ORC designations for all permits. This
information can be verified using the eDMR Owner Information Search provided on the
eDMR website. This information is maintained in the DWR data management system, as
provided by the permittee, and contained in the permit issued to the Owner. Should any
discrepancies with this information be determined, the appropriate DWR contact should
be notified .so information can be corrected prior to registration. It is important that the
permit information be correct prior to eDMR registration.
Please provide all information in Parts A, B, C and D. An Owner signature is required for
eDMR registration. Should the registration information be incomplete, the registration
process may be delayed.
Part A: Owner Registration — Permit/Facility Information
Please provide a Permit Number and the associated facility information. Only a single permit
number is needed for registration. If multiple permits are involved, the permit number provided
will be used to identify the Owner and all associated permits. All associated permits issued to the
Owner will be registered for eDMR.
RECEIVED /DENR/DWR
NC eDMR Registration Form (Revision 3.1) SEP 2 2 2014 page l of
Water Duality
Permitting section

Part B: Owner Registration - Owner User Details:
Please provide the following information which is needed for creating the Facility Owner in
eDMR. The Owner is the legal entity to which the permit(s) have been issued and may be an
organization or individual. For an organization, the information provided for the owner details should
be the official contact person or the person with delegated signatory authority for the Owner.
Last Name:
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Middle Name:
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First `Name:
Phone Number:
Email:
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User Id:
(Assigned by DWR eDMR Administrator)
Part C: User Account Information — Submitters
Please provide the users, in addition to the Owner, who will need Submitter permissions.
Submitter permissions can only be assigned by the DWR eDMR Administrator. The Owner specified
above will be given full eDMR permissions including Submitter permissions.
The Submitter is equivalent to the individual who signs the certif cation 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. A
delegation of authority form is available from the eDMR website.
In addition to the User Details, please specify the 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.
NOTE. The Owner will be responsible for creating all facility users except those with Submitter
permissions.
In addition to the Owner and Submitter user, there are four additional 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 manage facility users. The
Facility User Administration Guide will provide the appropriate procedures for facility user
management
NC eDMR Registration Form (Revision 3.1 } Page 2 of 4

Submitter User Details
Permit No. (s):
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First Name:
Middle Name:
Last Name:
First Name:
Phone Number:
Middle Name:
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Last Name:
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Phone Number:
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Email:
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(Assigned by DWR eDMR Administrator)
Submitter User Details
Permit No. (s):
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First Name:
Middle Name:
Last Name:
First Name:
Phone Number:
Middle Name:
Email:
Last Name:
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ser ID:
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Submitter User Details
Permit No. (s):
First Name:
Middle Name:
Last Name:
Phone Number:
Email: I I User ID: I (Assigned by DWR eDMR Administrator)
Submitter User Details
Permit No. (s):
First Name:
Middle Name:
Last Name:
Phone Number:
Email:
User ID:
(Assigned by DWR eDMR Administrator)
RECEIVEDIDENRIDWR
NC eDMR Registration Form (Revision 3.1) T �+ �^ f �N Page 3 of 4
Watef Uualny
Permitting Section

Part D: Registration Certification:
I request the facility identified above be allowed to submit DMR data using the NC DWR 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 NC DWR 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.
Owne r(Perrnittee) 4NI
Owner (Permit ee) Sign - ure
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Official Title (type or Print)
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Please return the completed Registration Form to the NC Division of Water Resources
Fax: or Email: or Mail to:
(919) 807 -6498 eDMRadmin(-&mcdenr.gov Information Processing Unit
Attn: eDMR Registration
1617 Mail Service Center
Raleigh, NC 27699 -1617
NC eDMR Registration Form (Revision 3.1► Page 4 of 4

September 23, 2014
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699 -1617
Subject: Delegation of Signature Authority
Zooland Family Campground
NPDES Number NCO089052
To Whom It May Concern:
By notice of this letter, I 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 Zooland Family Campground as required by all
applicable federal, state, and local environmental agencies specifically with the
requirements for signatory authority as specified in 15A NCAC 213.0506.
Alan Reitzel Gaddis
William Keith McDonald
Roieana Howard McDonald
Wastewater Consultant
Wastewater Operator -ORC
Wastewater Operator - Backup
If you have any questions regarding this letter, please feel free to contact me at 803 -799-
9683.
Sincerely,
Alec Chaplin Jr.
Owner
cc: Winston Salem Regional Office, Water Qujjetfft 1 IVR
SEP 2 2 2014
Water Quality
Permitting Semen