NC0037001_Signature Authority_20170712

Date. 1-7
RECENEIACDE*%R
jUL 21 2017
Wastewater Branch water Quality
Water Quality Permitting Section Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
Facility Name:t���}'1y
NPDES Permit Number: N I C 1010131 X11010 i t
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
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 42 (if applicable)
Name:
c)na) Gfenn ke-r
rpaviAllen &ehn s
Title:
enan on
en dice eCkrnj cl an
Mailing Address:
341 coun, y 140mc, Od
ReIaSV (le NC 2-73-2a
3q1 G'Ounit/ 00me IZd
Iclsvllle, /J(- 7320
Physical Address:
(if different)
nos 'Ko� co, in r,+ t-11co ° COM
�'l0 3Lf-3a �D
Email Address:
er 3 4 . k-1 r . S
Office Phone:
(D _ 3/�-3a 170
Mobile Phone:
3 3&- d rI q- q — l 9
33& 5 5 2 3
If you have any questions regarding this letter, please feel free to contact me at either the phone
number or email address below
Sincerely,
XdihorizaW Signing Official's Signature
ole �a Paxks
Signing Official's Name (type or
Mailing Address
A s s is dao l &ui2er1 n k-nJen4
Title
Emaif Address
330-Lpa7-, 336-�?3�-a55�
Office Phone Mobile Phone
cc Regional Office, Water Quality Permitting Section
(Enter region name)

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
I, Donat(pnnted name), have the authority to make this request for
S (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 Il, 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
Donald rslPnn Wal ka
/9wia,er/Re'ssponsible Official Name (type orpnnt)
�-Gvarrer/Responsible Official Signature
North Carolina General Statute § 143-215.613 provides that:
Mai nLe-n nn-- I c_Mr)1'ci an
Official Title (type orpnnt)
"7- s-- (�
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)

RESPONSIBLE OFFICIAL AUTHORIZATION
The Responsible Official, as identified in accordance with Part Il, 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
I, DQy I d 911,cii &e_ jnq—s (printed name), have the authority to make this request for
F-Dakinabam Coun±q 5rhophs (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 11, 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
1�c v id 1�n Gel i nas
0'70-'
le Official Na , e (type or pnntJ
/ esponsibIiaal Signature
North Carolina General Statute § 143-215.66 provides that:
M a► 4ena _) e�hn ► eiar�
Official Title (type or print)
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)