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Home My WebLink AboutNC0023086 Partialt A Responsible Official Signature The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate individual with the authority to sign and submit reports for the organization. r I, °lam { Pam' (printed name), have the authority to enter into this Agreement for (Owner/Organization Name). Ijc'Qoa302�% I request the NCDWR grant me and, if included in Sections C and E of this form, the named Submitter(s), an electronic signature credential to submit and accept documents electronically on behalf of my organization. I acknowledge that 1, and the individual(s) named in Sections C and E (if applicable), work at/for my organization and have authority to submit and accept electronic documents and act as a signatory for purposes of the NCDWR's electronic document systems. By submitting this application, I, ze° ter b e 60AU� (printed name), have read, understand, and accept the terms and conditions of this lectronic 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. G � t I e onsible O-fhcW Signature Title Da e 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: &leer I' e..a)QU-s @P6,'i nCoo t l qo- Qum User Id Subscribed and sworn to before me this -Z® day of 2011 01 %-AN �•,� Signature of Notary Pu CO J tv ; PAY v L =, min/y) C LGZ r, •U= '% pV�" ? 2 Printed Name of Notary Public °., GRP 00N l I My Commission Expires: (SEAL) NCDWR Electronic Submittal Agreement Version 1 06, 3) r" 1' Page 4 4 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. (printed name), am authorized by the Responsible Official name in this document, w o es authority under the applicable standards, to enter into this agreement for � w r" 6 hvt NLo,3O&4o (Owner/Organization Name). By submitting this application, I, �° /�'aa� (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. eac;�� - 04E 1?-9./S> Submitter Signatu Title Date �a�-�Dn��a�illccc�e.CDr� Email dAEmail dr 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 C� h day of 1t-r , 20_1�_ ZELERIE ROGERS NOTARY PUBLIC GRAHAM COUNTY NORTH CAROLINA W COMMISSION EXPIRES 4/,5/= (SEAL) 4ll Ikl Adf Sign re ofNotar rbAblic Printed Name of Notadj Public My Commission Expires: q 5 NCDWR Electronic Submittal Agreement Version 1 Page 5 > waterkesources FN ViRONneti [AL QLALITY Part A. PERMIT/FACILITY INFORMATION State of North Carolina Department of Environmental Quality Division of Water Resources EDMR REGISTRATION FORM 1. NPDES Permit Number: N I C 10 10 12 13 10 18 16 2. Owner/Organization Name: Town Of Fontana Dam 3. Facility Name: Fontana Dam Wastewater Plant 4. Facility's Physical Address: 12574 Fontana Campground Rd City: Fontana Dam State: NC Zip Code: 28733 Part B. OWNER USER INFORMATION 1. Responsible Official's Name: Zelerie Rogers Title: Town Administrator (Owner or duly authorized representative) 2. Mailing Address: Po Box 128 City: Fontana Dam State: NC Zip Code: 28733 3. Telephone Number: 828 - 498 - 2107 4. Email Address: zelerie.rogers@fontanavillage.com 5. User ID (Assigned by NCDWR eDMR Administrator): Part C. USER ACCOUNT INFORMATION 1. Facility Administrator Permission The Facility Administrator user permission can be assigned at the time of registration by the NCDWR eDMR Administrator. If someone other than the Owner will be responsible for managing facility users within eDMR and you would like the Division to set up the permission at the time of registration, then please provide the user details for the individual who will need the Facility Administrator user permission. Note: If this person will be responsible for submitting eDMR reports, then you will also need to request Submitter permission for this user. In addition to the user details, please specify the permit number(s) to which the user will be associated. If.additional space is needed, please make additional copies of the Facility Administrator User Details and complete as needed. Facility Administrator User Details Permit No. (s): NCO023086 First Name: Zelerie Middle Name: Dawn Last Name: Rogers Phone Number: 828 - 498 - 2107 NC eDMR Registration Form (Revision 4.1) 0 RESPONSIBLE OFFICIAL AUTHORIZATION The Responsible Official, as identified in accordance with Part II, Section 13.11 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, Zelerie Rogers (printed name), have the authority to make this request for Town Of Fontana Dam (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 NCDWRMnder 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. Zelerie Rogers Town Administrator Ze,,Respor, ible Official Name (type or print) Official Title (type or print) r '16A._6 September 4, 2019 O n r/Respons bye)Official Signature Date North Carolina General Statute § 143-21S.6B provides that: 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)