NC0020737_Delegated Authority_20141015

October 14,2014
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh,NC 27699-1617
Subject: Delegation of Signature Authority
Pilot Creek Wastewater Treatment Facility
NPDES Number NC0020737
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 Pilot Creek Wastewater Treatment 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.
Kim Moss Wastewater Plant ORC
Richelle Meek Laboratory/Pre-Treatment Analyst
If you have any questions regarding this letter,please feel free to contact me at 704-734-4525.
Sincerely,
Dennis R. Wells
Water Resources Director
Cc: NC DWR Mooresville Regional Office, Water Quality Permitting Section

THIS APPLICATION PACKAGE WILL NOT BE ACEPTED 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)
Applicant's Certification:
I, Dennis R. Wells, 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.
iCio /12.4a0 ry /q 20/y
Signature Date
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NC DENR/ DWR/ NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 11/13

RECEIVEDIDENRIDWR
State of North Carolina OCT 1 5 2014
Department of Environment • f
and Natural Resources permitting Secer tion
Division of Water Resources
Pat McCrory, Governor NCDENR
John E. Skvarla III, Secretary NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
Thomas A. Reeder, Director
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NI C I 0 I 0 120737 or N I C I G 15 I
1. Permit holder's name: City of Kings Mountain
2. Facility Name: Pilot Creek Wastewater Treatment Facility
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of: (Check one)
❑ a. Change in ownership of property/company
❑ b. Name change only
c. Other(please explain): Delegation of Signature Authority
2. New owners name (name to be put on permit):
3. New owner's or signing official's name and title: E)„t,, o,La,
(Person legally responsible for permit)
50,/Eros. c.f-4
(Title)
4. Mailing address: P. 0. Box 429
City: Kings Mountain
State: NC
Zip Code: 28086 _
Phone: [phone]
E-mail address: [e-mail]
[See reverse side of this page for signature requirements]
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 Telephone[phone] FAX[phone]
An Equal Opportunity Affirmative Action Employer 50%recycled/10%post-consumer paper

October 14,2014
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh,NC 27699-1617
Subject: Delegation of Signature Authority
Pilot Creek Wastewater Treatment Facility
NPDES Number NC0020737
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 Pilot Creek Wastewater Treatment 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.
Dennis R. Wells Water Resources Director
If you have any questions regarding this letter,please feel free to contact me at 704-734-0333.
Sin ly,
n. 1 1, izidtii_<fri
M . yn H. Se ers
Ci Manager
Cc: NC DWR Mooresville Regional Office,Water Quality Permitting Section

DWR
Division of der Resource!
North Carolina(NC) eDMR Reports
eDMR Registration Form
EDMR is an electronic reporting system,which will provide a facility Owner the ability to submit
discharge monitoring reports via the interne. 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 verb 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.
Permit Number: N I C 101 0 1 2 0 7 3 7
Facility Owner: City Of Kings Mountain
Facility Name: Pilot Creek Wastewater Treatment Facility
Facility Address: 200 Potts Creek Rd
Facility City: Kings Mountain Facility State: NC
Facility Zip code: 28086-
NC eDMR Registration Form(Revision 3.1) Page 1 of 4

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: Wells
Middle Name: Ray
First Name: Dennis
Phone Number: 704-734-4525
Email: [e-mail]
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 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. 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): NC0020737 NCO() NCOO NCOO NCOO
First Name: Kim
Middle Name: Teresa
Last Name: Moss
Phone Number: 704-739-7131
Email: [e-mail] User ID: (Assigned by DWR eDMR Administrator)
Submitter User Details
Permit No.(s): NC0020737 NCOO NCOO NCOO NCO()
First Name: Richelle
Middle Name:
Last Name: Meek
Phone Number: 704-739-7131
Email: [e-mail] User ID: (Assigned by DWR eDMR Administrator)
Submitter User Details
Permit No.(s): NCO() NCOO NCO() NCO() NCO()
First Name:
Middle Name:
Last Name:
Phone Number:
Email: User ID: (Assigned by DWR eDMR Administrator)
Submitter User Details
Permit No.(s): NCOO NCO() NCO() NCO() NCOO
First Name:
Middle Name:
Last Name:
Phone Number:
Email: User ID: (Assigned by DWR eDMR Administrator)
NC eDMR Registration Form(Revision 3.1) Page 3 of 4

Part D: Registration Certification:
1 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.
Dennis R.Wells
Owner(Permittee)Name(type or print)
Water Resources Director
Official Title(type or Print)
£ év h? October 14,2014
Owner(Permittee) Signature Date
Please return the completed Registration Form to the NC Division of Water Resources
Fax: or Email: or Mail to:
[phone] eDMRadmin(ncdenr.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