NC0059251_Signature Authority_20190524

DWR
Dlvlslon of Water Resources
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.
Type of Request (please select):
X 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:
NCO059251
Owner / Organization Name:
Quail Acres MHP WWTP
Responsible Official
(as identified in accordance with /0 C / R 122.22)
Lee Simaan
Street Address:
A
o eo l �^ f
City:�-
State / Zip Code:
01 �3S
Telephone number:
[phone]
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 Suhmitter permissions.
The Submitter is equivalent to the individual who signs the certification statement on the back of the
Discharge Monitoring Report. The Submitter must bean 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):
NCO059251
First Name:
Chris
Middle Name:
Last Name:
Bitterman
Phone Number:
(252 ) 235-7933
Email:
[e-mail]
User ID:
[e-mail]
(Assigned bV NCDWR eDMR Administrator)
Select Request
Type:
® 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:
❑ Add User Permission
Add/U date 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:
Assi ned by NCDWR eDMR Administrator
Select Request
Type:
❑ Add User Permission
Add/U date User Permission as of Date):
❑ 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, Lee Simaan (printed name), have the authority to make this request for
Quail Acres MHP WWTP (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.
'6wner/Re4ponsible Official Signature Title Date
Please return the completed form to the NCDWR eDMR Administrator via:
Fax: or E-mail: or Mail to:
[phone] eDNiRadmin«Qnculenr.,ov 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

5-24-2019
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
Quail Acres MHP WWTP
NPDES Number NC0059251
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 213.0506.
Chris Bitterman
Area Manager
773 Sanford Avenue
Mocksville, NC 27028
[e-mail]
984-365-9160
252-235-7933
Name #2
Title
Mailing Address
Physical Address (if different)
Email Address
Office Phone
Mobile Phone
If you have any questions regarding this letter, please feel free to contact me at 336-382-
6783.
Sincerely,
Lee Simaan 2L
<Facility Officer's Title> 0
<Mailing Address> G S� , /1� e- Z 2,?s
Simaaninc@aoLcom
<Office Phone>
336-382-6783
cc: Winston-Salem Regional Office, Water Quality Permitting Section