NC0020061_Electronic Signature Agreement_20220707

N.C. Department of Environmental Quality
Division of Water Resources
Electronic Signature Agreement
I{ederaI reguIatimis require that electronic documews InUSI have vsl id electronic signatures ifTi11e 40 of
the Code of FederaI IteQtllations requires liandwritten signatures an the paper documtt nis ihey replace.
Valid electronic sign aturc rcfus to Mtn ctcctrenic signature oa an electronic docuniont that has bccn
created %vith all elecu-onic signature credential.
This L'• tectronic Signattire A gri;.clni nl. wh+;tt finaIizo E and approved, %Vitt a] IO% • the jndiV-Pdual s witlt
elecrrottic simature cn-Aentials to sign electronically a variety ofrequired permit doe mnertts in lieu of`the
sui mittaE oirsigrted paper er copies. The submitral of l'iectronic Discharge Moni[oring Reports (eDLMR)
wiI [ be auaI Lable once your el ctronic signature credentials are its pace. Some agree mcn[s for doctiMeIlt
submittals or accepta rice, as noted in [Ile Agreement Conditions (Section B.), are not currently available
elwrortically but are included here to have the agrcements its place and to avoid the rtced to complete
fixture subrrtinal o1`agrecment fonus when thc;e kystems are initiated.
A. Owner/organization Information
OxvnerfO anixation Name: .
Re-9 pan sible Official: -
(as ideniilik:dill aLxmrqj;11rrx%wil[k40CFR 122-22}
Street Address:
e, . _ N t
State IZi
Phone Number:
)small Address:
`emai I wi I r be the pri many melbod of ccmWl for Inc cicclmnic
suhinimal process so it is imisorlonk to have on occurs is emai I
H. Agreement Conditions
To receive and accept the r quired electronic signature credential. consisting of user narxle and
password. iss[ted by the 14orth Caro Iina Division of Water Resoulces {N€CDWR) to order to Ml -11
electronic documents submitted to NC EIcoroil I Doc Lime tt Systcros :illd to rcccivo elcel ronic
dOCUments rrom NC systems:
-Jle € esponsibla O iciai artd 5AMi(ter (if applicable) named i n tIll s form do lie rby,
T. Ualders-Lmrtd tliai taxis Electronic Signatkirc Agreemk rtil roqhires me to stibinit t!1ectr ilc docomem." to
NC.DWR's apl}t'[ vad eD-MR �;yStein un€ er the alit arlm-d pr{}+ min iri Ilcu of paper subin issiorm
LlndeNuand ilia[ this Electronic Signeturc Agreement requires me to accept electronic transinissions-
in 1ictI of pajxcr transmissions of att permits. peranit modi i1cations, atilhorizltinns to congmir,1, and
any othizr com-spondence re Wed to reviewing and processing permits from tNCDWR. 1-his
mlLhorin(lon w i I I not become effective iinti1 W DWR estabIkhes a system for processiLig electrmic
documents; !am notified in writing from NCDI%-R €hat use o f the e lect ronic systems has officiaf[y
been initiated; and Norlh Carol ina rtIIcs and StBt4ues are changed [o a I I Ovv the intPleMerl Iarian or
electronic albmitual rind "Iec l lanCe 0rdoeumen1s.
NOW Electronic Submittal Agreement Version 1 Page I

U iidcrs1Wid LIMt 1111S 1,10�iroIII C 5iti11alLIrc A L, rec 11 ici 1 t rcgL11rC.5 1111' 11.0 S11billi1 C1Ci ll-011ic rill rn;cxs,rtrY
irtFormat [on For nroce%sinc of NPI]1-5 aplslIcat ion IneItldlli inlonnatioll for vene +°a1 Ofeslist ill-
liermits- truodificat inn to eximinti, permits, and appIicado11s Jor neti%- 0 Isc 1ri rlje Ile raili::. The sktbmiiials
n1tty inclu6c rIII necessary applications and suj3pnttiriv doeumettlation to CI VP'; approved gys(iew
fo3` c[cc trol7ic sklbmittals in f ieu cif paper subrnissiLins. This authorization vv i I I nol tvco nle effecIivc
nntil -INC I V4'R cstabfislles tt sYst ark for I)roctissitrygelectrcxtlic dottiIII Llr ks: 1 attt no lific*ct ill %%'riling from
NC'DW.R Ehal Lrse 0f1.11e e[CC lrartic syslcros has off ieialIN beLm initiaic& and North Carol inks dales and
5tatu10% 0rl chfined I€I allow Ilie iill P1cmCaln11oil of C1CO1-011tt �,AIll iltill and accclltancc (if
docunlcnts.
l:itdeFS1and khat khis Electrollic SiLpldhwe AgreenleM vequIstis wee io accept etectrotlic ssukimissions. ill
]iL:Lt ol'paper submissions, ofali Ploticcs of Deficiency, 'volices of viulations, Civil Mrially
Assessments. and any other correspondence related to cempllance with federal and slate ��'Awr quality
IRWS a]ld r4�L)LLlatlorls that Mig1l1 be sctu Icy i*1C'I)UI�'I�. 'lids �tltltic�rizalinrti ti� i II not Iit'CL?11�1r efl`et five
Lim iI NCDWR cstahJishes a sysIQrn for processing electronic doculncnts; ]yam not ilicd in Lvri6ng froln
N,C't0)R tltsl( Use Qf the eIcctrani c systen3S has ofi Icial Iv be m 1 nttlatcd: and No1'l11 Carolina vuIes and
Slatules are Owl - LA I -dI10, ' Ilse implemerl alic1Il of eleCtrollic sub1111rta] and acceptancc of
douu133ti1ls.
Agree to l)rolect both the tlec:Evan le signattire credCIltiit]. consisting ofrrlv user name and password.
and securky cttiestions and ansv ers. from uortlpr€kntise and from use by.inytiije- exL:elri ille,
SlICU I J I C111 IV r I'1grec tp Mal 1iluii1 taleorril%, electronic signature c:redential atld sec uriIv
gtiemions and answers: I w i I I nut d'ivuIvge or dcle to m,,- creden6a] or sec tidty questions and R115tti'i`1S
it) 111) darter 1lid ividtla1, 1 IV;II not Slorc my crs:denlial orsccurity yuestlorls and a3Ls11-ers ill an
LIIiprotecied Iacation; acid 1 wi II riot allim my q•lcell-ortic sit nature credential or securit%- questitit rs and
answers 1{1 he J} rittrn into cumlr�lleT scripts to achieve automated Icg-in.
6- Understand and agrLe IhEa ] 4k1II tie heid as IeagAIIV hL)LIt1 1. ob]igaled. all responsi1Ae for kite use of-nn
cicctro3lic sisnaturc as I WOUld hL usirlg M% It�llttl-tixritren sifillaLurt.
7. Linderstand that I kri l l be inlorin d tllrc ugh 1ny rcgistcl-Q0 clxlai I :u &C-9s W11C11C YOI• mY LksCl' nuino or
password ]las b4cn nloditaeCl. '
S. Undenstand that eD?vIR reports ratio Iasi dme 111\' LlsrL!r 1ltllllt a n J password 11'Cl— LrL,ed ilnmedimeIv at'ter
successlulty fogging into cDMR-
. A rce to contact the NC-I)WR el} IR Adnil nisiraior v-a cinal I at st.l)�1a3, i&iin ; nctlt t3r,um as sonar
tks possible. bill no Irlter ifian 24 I10131-s. aficr suspecti3lg otr delerill ininip that lily rt,%cr namii r1lidfclr
password 11ave become Jost- sroten or otttor%% isc col iip17omised,
10- Agree t11131 l will rcvIrw the contenis t)I'aII electronic subIll issions }prior to sL3bIII ission-
1- Utldcr2M111 J ttlsit i W i I I ;3LLI0111atiCal IN' rcC6ve an uilia i1 1`'`ceipt at my regkteretl eminiI acidr45s 1 fool the
CDWR's ;DM;DMR system for any Stlhmk -sion tartar cowarns a val.1d ctecLuoluc signature, identifying
Elie dacuillknt received. the signatory. grid (tte date and tiinc t1f receip(.
2. Agree to contact k h e INC't)WR eD'vtR Administr�itor vui cmaiI ill cD3\IRadnt111 it Itcifenr �Li� it I do nL)t
rcceive an email receipt as specified above wiIli ikl live C 5 ) business clays for rind' electronicaIIy signed
submission usinr: my credelltials_
13. three that if 1 received an e€rtai1 not Iication for an ai 211 v Ity that I do not believe that ] WILfoxrined, I
tivlli noiiFv the NCDWR eD-MR Ado) ill istraior via einai! at LD-MRadmin-di1cdellnlggv 415 S0011 of
possible. but no later illan 24 hours. at'rer recei pt-
NCDR Electronic Submittat Agreement Version 1 Page 2

14, !Agra.: tc) rLrI)ort. %Y.iIIrin 2� hours ol, discoVCF% -Elul evidcrxtL� 0f disCitPitnc%' Li: tWM3 itt3}- t ICCtF011iC
document 1 hn vo signed grid wbm -Ft wd all IV hat the NC'[]WR eDLMR 1las reccivcd from me by
contactatlg the b]CDWR eDMR Adminisiriltor via email at eDNIl6diniii cr ncdeirr-4FLi%-
l�, �1]<I��'stcncC 11�;tt i]]C l�i�'i)1�Vi� C]•.)1�1f�'s �ystcm 1�ill �tt3t(]l3]�liC�►II�� rcjCct it11V (;Icctrc�nic clixr;ua��eiu
sLLbrnitLt!d 11-itlimii ,L vaIid clectruitic signature i f such signawrc is rcquii-ed
16. Agree to contaci tine NCDIAI R c[)M R Admitiistrator vio email tat t:DNI k,. do—ni11 rr 11ciletlr.4LoV with[rl
ten % or•king days if mY dtatics chapige and I no [nngcr need to iweract with c[).MR cn hehalI-of-tnL
c}r•�isr�i��t#irrn.
17. Agree it) n« ldl - the NrCDWR eD1v1 R Adinirilmrator via cmaiI at > I i n rr. mtlettr.Lox 11 [ cease
to rcprescnt the regulated entity specified above as signatory of flMl oi•�,a1fir:LtiO WIL c[ecvonic
submissions as 50011 as this Chatlgc ill i•elatiUll-drip rlt:t:rill,
] 9- Understand that the NC'D%VR may contacI Ilie Organization j Rcgxpjvl1-4e 0 111CUL1, 1V110 Si n% hC1011
to au(horiac me as a sinatory foi- Ilse 0wiler/Orpnizotir5ll, in order to veri P-r ally Idern iiy
19, Agree to stain a Cope afthis sigiled aprt;ement n-q long a1 I uominve to i-cpr sent (lie rcg43ialed ciithy
speciILed above as sigElatory OfIlie Ong -an iT-ati0ri's electronic %iibmisMort�.
20. Certify drat I have the authority to enter irilo 111i5 Aurcerrtcnt oil behaII-cif tIiL: Or-unixrttion iderttiCied
above, and I ai]] a Memory ,i[tt110 Jzed to rL!preserti Ii]uI UT-panizal ion. tend 1 a1M 81110 to siiF» ,Lncl
scthmiI Tvparis and other information [li] 1 1]811`t�f'tltxt i`7rganization in ilie capacity rt squired ht- ',calcite
�Illdl or Feguiation.
C. Pei-n)jUF::tciJity fnft,rtriitti()n
Approval t_talder Elvis i:lcctronii Sigryature Agreenicill is tlppIicab]c to tli iolIowino 1)ermiIs and if
i�pl)liUtblc 10 thtc 4crbmitiL~r-_ i1-11101ed litre aril iii SecliOil 1:-
-- IPernii[ -- - --
LNTum best Facility Nimc Fa c i I i ty Add res c ubill ittet-7 (ii ikfil}l LnIAL;)
i
b
You ilia% 01114 IncI ik rXrn11tS assuciawd witli One omier, 1I-rnore5pao: ISlieLi d rL)T.k1jhir7:likt ]'mlir5 or submium— WU
nia% ;kl[nt=i1 ;4eparLau pup:p , A supploillintal Sheet iL. Ivai lAhIt: ILL, Iltt ltx: d1tLk. Li:._4n'Ji %IVL 4I i%i\ll kl i %% ktir-
r, SOWLL s tdrnir rikr11a5-:1Lkd-erjy Lr1
A Lk-p-traaC koccl.iion I: illust tat inr]u(Jrd toreaCh -�4{Lbfflitt r in oYdrr Lo ditkin a huni c«pn.:ign.mlrc LL3)d 3101-LLriz:kLi{1d1 &v;111
cntitirs. I Fworc than one iridividLial k%iII ha%e -.m1lirtiilter permissiow. 1iir tlic mrrtr ixnnit. thell itldit lk! this 011 '�LIlartt�:
rcll4 s-
NCDWR Electronic Submittal Agreeirlent VeTsion 1 Page 3

1). Official Signature
The Ikt3spn11sible- 0Fill cial, aE id enIiI-jed in accord-mcc m-.11h 10 ('FIB. l -1 ' is Ehe appropri:ltc inclivoclull
%vith [lie authority to sign and submit r pakis liar tltiu or-irlli lion.
rim-blit(f :lrurpe). haw the auihnriIv t() �111 int() 113it
Agreement for p y
l ri�um Ilse JM"I}WR grant me alld, it' iryeluded in SUC60114 C WId I-. W'111i5 l6mr. Eht;i naiiwd Submirter(s).
all elecironic signalwe crederitial to stlbmil and accept d0CL1111e11Es ola belt,ali al' ally
nrgani aki m.
I ackno►vicdpe INn 1. and the individual(s) reamed Gr1 Se-crions C and I: (if applicable), work- a0br- m►'
orpnimiion -Ind INVIT akrtllority- to 5ubill ii and acccpt elCttronic doc:tlnlertts and acr as n-.1gnamr) Ipr
pkirpnses of the NCDWR's electronic documem systems.
By silbrlli(tl rig this iippiicat iorl. 1, _ {, �, _ rirrrrrrrrf ircrMe)- 113VC read.
understand. mice tkcccpl i.1w terim aTtd umidi(10 s ill' Ellis F. lectmnic Si Tatar{ �rce33 ent. I certi fV under
penaliy elf lnvv chat I have personaI ly exall]irwLd grid s1rt1 fam11 iar witIi the inlarmation stihillitted iti 1llis
,�wi appIicatluii wid till atUchi s andthal9 Based on ilk' iiig4M11'1' of th{o5i� J)Qrso11S iill ktic diatejy respol1Slblc
far obtailling the inronTiEaion coil Fairticd ire the appIiOi-p n. I heIie%4 IhaE 111L inf6mizition is trttc. accurnli�
nrld com�)Iete- l am awaiv that there are. signi I kart penalties Ior subnuuing false inIbmiatiL511. illclLid ing
the possibility of Iint1 rind i1npriSLoii Qnt.
I���I,r}nsihie Ol�icial 5ign�atiirc
Email Addre2Ls
Title
S ).
llhottc Number
-4' S —;l a
Date:
'eMAI wi11 br. !Ix rxinnry mohtod oFvgPnE wt fin kFFc K14;;Lninic sabiuiktal pnocu-zi• mi is 6 jill1 xrai7I tkl % %4 jM aLCElFak LkiLiI
arailablc at all til w'.
I 'OLl are a cun-ent eD.MR strbmltter" I)Icase prc)v](Ic V0Lrr I Iser Id — —
Us,er Id
SuhscribM and \morn to hcfore me this day of .
W--avta-�-�L, 7- -- -..
h-'MAure vi`Notarp- i'4iblic
Printed Name o?"Nntar� i'EtFsl c
SANDF A I.V, h'DRF1;Iti
NALI
r�l�• �omm�ss�nn L�pirts: �o�C�.o`� --
�SGAI.)
NCOWR Hectronic Submittal Agreement Version 1 Page 4

E. Submitier- iujt:t ire
Thj tthmitter (electronic sign iUr applicaw is a user other thaLl the Respo115ibic OfTiciiiI w110 YLubniits
Ibis agreemem 11) rquesl to sip repE'ts The Sirbmiaer is inve i signatory aritfiorik
indivirltlal identified as the Re�ponsil}le Official by 1lie wnere'orga id 7w ion to sign reports and oilier
information and Lo accept electronic documents.
(pr•inledname), am authoriz-,cl by [lie Responsible Official
f7Ai73C i[i ll,ks d[}curneni- INho dom. l uve the aLi11)ority undci` the applicable standards. is i3lltu info thj
agreement fort pr��r4 .-—�1'tteTl�u+��-crfrrrr ;1Cr�ue.
By $ubmitLfiig tills appiIca tion, �- � r'i�1�T`�' � _ fpr'irrrednariTp1. have read
tmdcrsmnd. and ai;rxpT the tcrnus and conditions oftlli4 f:lectpun'Lc Sigm-aure Agcccrlisi1t. I ccl•tiPV Under
pena]IV o1'1a", [hat ] have personz�II y examined a11d am Iarnifim- wii11 the irirorm-minn !;ubrniut-Ni 1n tllis
ppIic#n[on and a I I atuachments and that. Lmscd on Tuy ingiiiry al those pusons I[Ttmedl.iicly rl~sporlsiblc
for obtaining the inFormation contented I11 the appljca ioil. I E6cllcye that the in orination is iru . accurzt:
and crr[Tlplete. I ixm nl vAr� tftat t11t�re are signiIis:aitt pcna[tic5 for $11bill ittiilQ false iIIf6rnrttion- ii1c]IIdi112
the possibility of-ftne and imp.isonment.
W-ftA�40-�m MAO
ubmitter SiLRUIRire i itkc [Jztic 1
Email Addr%.;�,� Phone tNumbcr
�cmaiI wiil be the arilm:r}- czj�010d93fpuraia I For chc dn;l micsubmi[taI proms --u is is imp umt to havc ziaacc[]ntw C[ all
mpilahlr ar all rimrs
Ifyou are a current cDMR subill itter plcase provide your Ustir Id-. -----
lfsi'r Id
Sujl rihcd and swum to 111�fcary [Tic th-rs t2u} of _
DEBORAH A. OXENDINE
NDTAAY PUBLIC
ii MNTY, N.C.
My Go-mmisslafl ExqIrua 11 fl5f1G25
(SEAL)
S[Un�jiLlf-� Of NQtaII' Public
I'FE[i a€1 i*lante of T�lttkr' ' PLIblic
Niv Commission expires; P —
N C DW R Efectror1ic 5ubm111�)I .green ono Versioo 3 page 5

E. Submittet' Sigilawre
TI3c SLIN11it[Cr (eleCtrcu)iC Si5-11Taturc al)l)l i0lPit) is a Llher 01he1' thaal the Itcsymnsihle CAficial %vho submits
this aurccnlcns t1) rcgHesi to sign reports dectronica11y. -1-he Submittcr is i ven si-nalory authorit, b an
individual iiclltifled as the Re-gpon;ible 0ITLeial by the Owlic 00 rgani7211on to sign report, and tether
inrorination acid to accept L~Icctronic doct moms.
1, �F Iy4 Q f gn-i?Fi d ��cune, am authori/ed b} the Responsible 0IT1cia1
n tnyc in this ljcac ncnt, }} 110 dut.s l IkEvr the Hialioriiv ujider Ehe App]Icable SMlidards- io cnler irlr�l dais
a<<reemcnt for R:)4-3 rs A 1 v) r1'runef.
B". submilling iltis applicalitm, 1, = C cL ct cl lfxr�risrreff nfvple�. have rca1
Lnidcrmand. and acct:pt the [cmis and conditioi-&vf-this Llectronic Signature Agnwemcvt. ! "rlifv tirtder
perralt} 1f 1aw t11at I Iinve pemannIlti+ examined and ain fain iIiar wiIh the inloi-inatiGn wbrilltTed I re I11h,
application and all attaclmlcuts and that. based pit m}' 111(lL1ER' 4lrrll(Y.5 PCM0114 1rT1111CdiHkc1}' YC'ij Qxlsibl
for obtainirig thw jnI-ormation coilt&ived in Thkr application, 1 beIieve tlraL tIle infiorrllZIIi err is true. k1UCUNIC
and ccniplete- I nil aware t]1K-kt there art: sigrti11canI penaIIics ror subin false juforanaliori, €ncIuding
Fist POS& ili hY or rjjw arrd � x isoauuc,al,
lhm'it'terLnatLkre I itic ' ., Date r
f:nlaif Address r f'11011c Number
"entail +x ill K the Rrimur% rnrthixd vfuA l.ao for kix tilwLA;lrolik suhmill al pRwxg,5 v) i1 is imporsuic io huxk .w ur uralt Cr11.El1
M-ailahlu atalI limos
Ii" N'ou nrw a eurrew t--NM R stibin ilter p]crtse provide your Use-r 10
t istr Id
Silbscrii Lxf and sworn to bck}rc n1C this da". of
Tn
Str?n,-rture c}f` IN, Pixy Public
Printed Blame 0, Nottu•.v PLkbllc - — - �—
SANDRA W. HORRIS
ROTARY PUBLIC
y Commission--
(SL•AL)
NCOWR Electrenfr. 5vbrnittal Agreement Version 1 Page 5