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Home My WebLink AboutWQ0005849_Signature Authority_20220726ROY COOPER Governor MICHAEL S. REGAN Secretary S. DANIEL SMITH Director Division of Water Resources Non -Discharge Branch 1617 Mail Service Center Raleigh, North Carolina 27699-1617 To Whom It May Concern: NORTH CAROLINA Environmental Quality July 26, 2022 Subject: Permit No. WQ00 Signature Authority Designation FACILITY SELECT System COUNTY County As an appropriate signing official for _ %�/�l� i 5 L. L, (city/town or business name) as designated by 1SA NCAC 2T .0106, I hereby delegate authority to sign and certify all permit applications, reports or other permit related documents to the following staff for the following permit types (sewer, spray, land application) and/or permit numbers. Position Person Currently in Position Permit Type or Permit Number %mac i N; r T (,tJ c� ` q/ If you have any questions, please contact me at the following: Penrlittee/A plicant name (please print): Title: ��/-I,cC Complete mailing address: /CAS 5 " l") State: North Carolina Department of Environmental Quality � Division of Water Resources 512 North Salisbury Street � 161T Mail Service Center � Raleigh, North Carolina 27699-1617 919.707.9000 N.C. Department of Environmental Quality Division of Water Resources Electronic Signature Agreement Federal regulations require that electronic documents must have valid electronic signatures if Title 40 of the Code of Federal Regulations requires handwritten signatures on the paper documents they replace. Valid electronic signature refers to an electronic signature on an electronic document that has been created with an electronic signature credential. This Electronic Signature Agreement, when finalized and approved, will allow the individuals with electronic signature credentials to sign electronically a variety of required permit documents in lieu of the submittal of signed paper copies. The submittal of Electronic Discharge Monitoring Reports (eDMR) will be available once your electronic signature credentials are in place. Some agreements for document submittals or acceptance, as noted in the Agreement Conditions (Section B.), are not currently available electronically but are included here to have the agreements in place and to avoid the need to complete future submittal of agreement forms when these systems are initiated. A. Owner /Organization Information Owner/Or anization Name: - Responsible Official: as identified in accordance with 40 CFR 122.22 Street Address: /U k/ U City:q State / ZipC lP U Phone Number: Email Address: ��TP��o�{�l/��r sLG5f1, �O/✓� *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 B. Agreement Conditions To receive and accept the required electronic signature credential, consisting of a user name and password, issued by the North Carolina Division of Water Resources (NCDWR) in order to sign electronic documents submitted to NCDWR's Electronic Document Systems and to receive electronic documents from NCDWR's systems; The Responsible Official and Submier (if applicable) named in this form do herby: 1. Understand that this Electronic Signature Agreement requires me to submit electronic documents to NCDWR's approved eDMR system under the authorized program in lieu of paper submissions. 2. Understand that this Electronic Signature Agreement requires me to accept electronic transmissions, in lieu of paper transmissions of all permits, permit modifications, authorizations to construct, and any other correspondence related to reviewing and processing permits from NCDWR. This authorization will not become effective until NCDWR establishes a system for processing electronic documents; I am notified in writing from NCDWR that use of the electronic systems has officially been initiated; and North Carolina rules and statutes are changed to allow the implementation of electronic submittal and acceptance of documents. NCDWR Electronic Submittal Agreement Version 1 Page 1 July 28, 2022 Wastewater Branch Water Quality Permitting Section Division of Water Resources 1617 Mail Service Center Raleigh, NC 276994 617 Subject: Delegation of Signature Authority ENTER FACILITY NAME NPDES Permit Number NC 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 #2 (if applicable) Title: Mailing Address: ADO/ f !0 5&(eAC 5 F' Physical Address: (if dierent) Email Address: Office Phone: /v - 327 -;U&F o - MobilePhone: If you have any questions regarding this letter, please feel free to contact me at Enter Email or Phone Number. Email Address ! A �LAR �A� �LUC Su SA. Cam Office Phone 2� �, 220. 3� � "Z Mobile Phone1 k cc: Select a region Regional Office, Water Quality Permitting Section 14. Agree to report, within 24 hours of discovery, any evidence of discrepancy between any electronic document I have signed and submitted and what the NCDWR eDMR has received from me by contacting the NCDWR eDMR Administrator via email at eDMRadmin cgncdenr.gov. 15. Understand that the NCDWR eDMR's system will automatically reject any electronic document submitted without a valid electronic signature if such signature is required. 16. Agree to contact the NCDWR eDMR Administrator via email at eDMRadmin(a�ncdenr.gov within ten working days if my duties change and I no longer need to interact with eDMR on behalf of my organization. 17. Agree to notify the NCDWR eDMR Administrator via email at eDMRadmin(a�ncdenr.gov if I cease to represent the regulated entity specified above as signatory of that organization's electronic submissions as soon as this change in relationship occurs. 18. Understand that the NCDWR may contact the Organization's Responsible Official, who signs below to authorize me as a signatory for the Owner/Organization, in order to verify my identity. 19. Agree to retain a copy of this signed agreement as long as I continue to represent the regulated entity specified above as signatory of the Organization's electronic submissions. 20. Certify that I have the authority to enter into this Agreement on behalf of the Organization identified above, and I am a signatory authorized to represent that Organization, and I am able to sign and submit reports and other information on behalf of that Organization in the capacity required by statute and/or regulation. C. Permit/Facility Information Approval under this Electronic Signature Agreement is applicable to the following permits and if applicable to the Submitters, if noted here and in Section E: Permit Numbers Facility Name Facility Address Submittee (if applicable) . f /ir2L /o9Sf /o f aa/ 1. You may only include permits associated with One owner. If more space is needed for additional permits or submitters you may attach separate pages. A supplemental sheet is available at: https://deq.nc.gov/about/divisions/water- resources/edIII forms -and -reports 2. A separate Section E must be included for each Submitter in order to obtain a hard copy signature and notarization for all entities. If more than one individual will have submitter permissions for the same permit, then indicate this on separate rows. NCDWR Electronic Submittal Agreement Version 1 Page 3 r 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 i�document, who does have the authority under the applicable standards, to enter into this agreement for Z.C.( s ILL C (Owner/Organization Name). By submitting this application, I,,'��rl`� ±52W=,Zz (printed name), have read, understand, and accept the terms and con ' ions 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. u7JmL± llk;5Pffca- Title Date 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: User Id Subscribed and sworn to before me this � day of L%uILL.� 20 � � . 1060TAR (P O 'OUBL\G V �/Zow Co\pI \�� (SEAL) Signature of Notaty Public Printed Name of Notary Public My Commission Expires: /o� � C%�� NCDWR Electronic Submittal Agreement Version 1 Page 5 D. 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. (printed name), have the authority to enter into this Agreemen for (Owner/Organization Name). I request the NCDWR grant me and, if included in Sections C and E of this form, the named Submitter(s)5 an electronic signature credential to submit and accept documents electronically on behalf of my )rganization. I acknowledge that I, and the individuals) named in Sections C and E (if applicable), work abfor• 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, /r,/,"T �e a,�i (printed Warne), 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. / Respo s ble Officra Signature d.�e'_��f�'SG.�PF717/c%P�S��.9•. ['eye Em Address GIANT �'1'►��1�2 Title Phone Number Date *email will be the primacy 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 .� day of 20� �0TA/�Y o pUBL�G V leow Coov \��. (SEAL) Signature of Notary Public Printed Name of Notary Public My Commission Expires: � �a o��oZ�c NCDWR Electronic Submittal Agreement Version 1 Page 4