NCS000369_Owner Affiliation_20201119

McCoy, Suzanne
From: Ace May <[e-mail]>
Sent: Thursday, November 19, 2020 3:10 PM
To: McCoy, Suzanne
Subject: [External] NCS000369 Fayetteville Public Work Commission Butler -Warner Generation
Plant
Attachments: NCS000369FayetteviIle PWCRes ponsibleOfficaIChangeForm. pdf;
NCS000369FayettevillePWCStormwater_eReporting_Registration_Form.pdf
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
[e-mail]
Mrs. McCoy,
Per our phone conversation I have attached our change of "responsible official" form and the e-registration form for the
eDMR Stormwater program. I have not uploaded any forms yet, I wanted to send them to you first and see if everything
looks ok. Upon your approval I will upload them and also send you the hard copy originals through the mail.
Thank you for your assistance in this and please let me know how and when to proceed.
Power Plant Manager
Fayetteville Public Works Commission
Butler -Warner Generation Plant
Phone [phone]
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Ii !v�E TOWN UTILITY
From: Ace May
Sent: Thursday, November 12, 2020 9:46 AM
To: [e-mail]
Subject: NCS000369
Suzanne,

I have some questions regarding our completion of the process to enter the eDMR system. I also have some questions
regarding the responsible person change. If you could please call me at my number below.
Thanks,
W%/.a/, Power Plant Manager
Fayetteville Public Works Commission
Butler -Warner Generation Plant
Phone [phone]
[VMS
E €Qr%4 E•: I'(O_WN U TI I, ITY
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Division of Energy, Mineral, and Land Resources
Land Quality Section / Stm•mwater Program it
( %
National Pollutant Discharge Elimination System (NPDES)
Energy Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
L and Resources
ulvuunluculsl aueuly (Individual Legally Responsible for Permit)
Use this form if there has been:
POR AGENCY USE ONLY
Dale Received
Yenr
March Un
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownership of the facility has changed,
do NOT use this form. Instead, you must fill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally respmrsible individuaP' mean?
The person is either:
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, federal orother public
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
I) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
hidividual Permit
UUMM
2) facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N C G
Butler -Warner Generetlon Plant
Fayallevllle Public Works Commission
2274 Custer Avenue
Address
Fayetteville NC 28312
City Slate zip
To find the current legally responsible persmt associated with your permit, go to this website:
hops://deg.nc.Qov/about/d i v i sions/enereY-m i neral-land-resources/enerav-mineral-I and -permits
program and run the Permit Cmrtnet Summary Report,
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Marlon
4) NSW OWNER AFFILIATION (legally responsible for the permit):
Person
legally responsible for this permit:
Noland
pan
LflSI
William C May
Pirsl MI Lnsl
Page 1 of 2
S Wll-OWNERAPPIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Power Plant Manager
Title
PO Box 1089
Mailing Address
Fayetteville NC 28302-1089
City State Zip
( 910 ) 2234814 [e-mail]
Telephone E-mall Address
Fnx Number
5) Reason for this change:
A result of; ❑Employee or management change
0 Inappropriate or incorrect designation before
❑ Other
If other please explain:
..................................................................................................................
The certification below must be completed and signed by the permit holder.
Y)✓RMITTCC CCRTIFICATION:
1, 91 �.% � - t ♦.two �, attest that this application for this change in Owner Affiliation
(person legally responsible for the permit) has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this form are not completed, this change may not be
processed.
Sign re Date
YLEAS); S)CNll TH); COMPL);T>;D FORM TO.
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699.1612
For more information or staff contacts, please call (919) 707=9220 or visit the website
at: httu://deq.no.stov/about/divisions/energv-mineral-land-resources/stormwater
Page 2 of 2
S WU�OWNBIiAFP(LdNov1019

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental Quallly
Stormwater eReporting Registration Form
Completion of the Stormwater Electronic Reporting (eReporting) Registration Form is a required
step for the Owner to obtain the privilege of submitting electronic reports to DEQ and in lieu of
submitting paper reports.
In addition, this form allows for Owners to designate Responsible Officials and Facility
Administrators who can act on their behalf. Responsible Officials and Facility Administrators
must agree to the Electronic Signature Agreement (ESA) Conditions contained in this form.
A. Owner Information
The Owner is the legal entity to which/whom permits have been issued. The Owner maybe an
individual or organization. Every Owner is required to have a Responsible Official who meets
the legal signature authority requirements in 40 CFR 122,22,
• For a corporation, this individual shall a president, secretary, treasurer, or vice-president in
charge of apt I ictpat business function, oranotter individual who performs sinwarfunctlons
for the corporation, or the manager of one or more manufacturing, production, or operating
facilities who is authorized to make management decisions about the facility operation.
• For a partnership or sole proprietorship, this individual shall be a general partner or the
proprietor, rospectively, or
• For a municipality, State, Federal, or other public agency, this individual shall be either a
principal executive officer or ranking elected official.
Owner Name:
Fayetteville Public Works Commission
Responsible Official Name:
William May
Title:
Power Plant Manager
Does the Responsible Official
already have an eDMR account?
0 Yes M No
If Yes,
User ID:
Email Address:
[e-mail]
Phone:
910-223-4814
Mailing Address:
PO BOX 1089
City:
Fayetteville
State:
NC
Zip:
28302-1089
Stormwater Electronic Reporting Registration Form
Page 1

B. Permit Information
Include all storm water permit currently held by the Owner (both Individual and General permits).
Designate any persons to be designated as Facility Administrators for each permit. Include all
persons to have Facility Administrator privileges in the same box. Attach additional pages if you
need more space.
Permit No. I Facility Name I Facility Address
NCS000369 Butler -Warner Generation Plant 2274 CusterAve Fayetteville,NC 28312 Terry Rayner
Stormwater Electronic Reporting Registration Form
Page 2

C. Facility Administrator Information
Include the following information for all Facility Administrators listed in Part B. Attach additional
pages if you need more space.
Facility Administrator for Permit Number:
Name:
Terry Hayner
Title:
Operations Supervisor
Do you already have an eDMR
account?
®Yes No
If Yes,
User ID:
Organization:
Fayetteville Public Works Commission
Email Address:
[e-mail]
Phone:
910-223-4236
Mailing Address:
PO Box loss
City:
Fayetteville
I State:
NC
I Zip:
28302-1089
Facility Administrator for Permit Number:
Name:
Title:
Do you already have an eDMR
account?
13 Yes El No
If Yes,
User ID:
Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Facility Administrator for Permit Number:
Name:
Title:
Do you already have an eDMR
account?
®Yes 0 No
If Yes,
UserlD:
Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Facility Administrator for Permit Number:
Name:
Title:
Do you already have an eDMR
account?
13 Yes ®No
If Yes,
User ID:
Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Facility Administrator for Permit Number:
Name:
Title:
Do you already have an eDMR
account?
®Yes ®No
If Yes,
User ID:
Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
_
Zip:
Stormwater Electronic Reporting Registration Form
Page 3

D. Responsible Official Authorization
William May
(printed name), certify that I
meet the legal signatory authority requirements under 40 CFR 122.22, to make this request or
behalf of Fayetteville Public Works Commission (Owner/Organization Name).
//�x � Z V 6 /
Sig u e Date
Stormwater Electronic Reporting Registration Form
Page 4