NC0079740_Delegated Authority_20141014

October 14.2014
RECEIVED/DENR/DWR
Wastewater Branch OCT 1 5 1U 14
Water Quality Permitting Section Water aunty
Division of Water Resources Permitting Section
1617 Mail Service Center
Raleigh,NC 27699-1617
Subject: Delegation of Signature Authority
T.J.Ellison Water Treatment Plant
NPDES Number NC0079740
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 T.J.Ellison Water Treatment Plant 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.
Newt Henson,Jr. Water Plant ORC
Larry Deal Water Plant Chief Operator
If you have any questions regarding this letter,please feel free to contact me at 704-734-4525.
Sincerely,
D‘Avic4 tozeL.
Dennis R. Wells
Water Resources Director
Cc: NC DWR Mooresville Regional Office, Water Quality Permitting Section

THIS APPLICATION PACKAGE WILL NOT BE ACEPTED BY THE DIVISION UNLESS
ALL OF THE APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE
SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
Applicant's Certification:
I, Dennis R. Wells, attest that this application for a name/ownership change has been
reviewed and is accurate and complete to the best of my knowledge. I understand that if all
required parts of this application are not completed and that if all required supporting
information and attachments are not included, this application package will be returned as
incomplete.
)T1P. 4 /o- /y-. 1‘1
Signature Date
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NC DENR/ DWR/ NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 11/13

Submitter User Details
Permit No.(s): NC0079740 NCOO NCO() NCOO NCOO
First Name: Newt
Middle Name:
Last Name: Henson Jr.
Phone Number: 704-482-7131
Email: [e-mail] User ID: (Assigned by DWR eDMR Administrator)
Submitter User Details
Permit No.(s): NC0079740 NCOO NCOO NCO() NCOO
First Name: Larry
Middle Name:
Last Name: Deal
Phone Number: 704-482-7131 J
Email: tar el- of ialQ Cil Y Aliteom User ID: (Assigned by DWR eDMR Administrator)
Submitter User Details
Permit No.(s): NCO() NCOO NCOO NCOO NCOO
First Name:
Middle Name:
Last Name:
Phone Number:
Email: User ID: (Assigned by DWR eDMR Administrator)
Submitter User Details
Permit No.(s): NCOO NCO() NCOO NCOO NCOO
First Name:
Middle Name:
Last Name:
Phone Number:
Email: User ID: (Assigned by DWR eDMR Administrator)
NC eDMR Registration Form(Revision 3.1) Page 3 of 4

Part D: Registration Certification:
I request the facility identified above be allowed to submit DMR data using the NC DWR 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 NC DWR under 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.
Dennis R.Wells
Owner(Permittee)Name(type or print)
Water Resources Director
Official Title(type or Print)
,12! Gaw,e6 October 14,2014
Owner(Permittee) Signature Date
Please return the completed Registration Form to the NC Division of Water Resources
Fax: or Email: or Mail to:
[phone] eDMRadmin(&ncdenr.gov Information Processing Unit
Attn: eDMR Registration
1617 Mail Service Center
Raleigh,NC 27699-1617
NC eDMR Registration Form(Revision 3.1) Page 4 of 4

State of North Carolina RECEIVEDlDENR1DWR •
Department of Environment OCT 1 5 2014 • •
and Natural Resources
Division of Water Resources Water Quality
Permitting N C D E R
Pat McCrory, Governor
John E. Skvarla III, Secretary NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
Thomas A. Reeder, Director
, PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
PermitNumber: N ► C ► 0 ► 0 ► 79740 or N ► CG ► S ►
1. Permit holder's name: City of Kings Mountain
2. Facility Name: T. J. Ellison Water Treatment Plant
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of: (Check one)
❑ a. Change in ownership of property/company
❑ b. Name change only
c. Other(please explain): Delegation of Signature Authority
2. New owner's name(name to be put on permit):
3. New owner's or signing official's name and title: /A-1,,k, P. GA.?-e.
(Person legally responsible for permit)
L44tr �Csou rc‘s Dircet-or
(Title)
P. 0. Box 429
4. Mailing address:
City: Kings Mountain
State: NC
Zip Code: 28086-
Phone: [phone]
E-mail address: [e-mail]
[See reverse side of this page for signature requirements]
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 Telephone[phone] FAX[phone]
An Equal Opportunity Affirmative Action Employer 50%recycled 110%post-consumer paper

October 14,2014
RECEIVEDIDENRIDWR
Wastewater Branch OCT 1 5 2 014
Water Quality Permitting Section
Division of Water Resources Water Quality
1617 Mail Service Center Permitting Section
Raleigh,NC 27699-1617
Subject: Delegation of Signature Authority
T.J.Ellison Water Treatment Plant
NPDES Number NC0079740
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 T. J.Ellison Water Treatment Plant 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.
Dennis R. Wells Water Resources Director
If you have any questions regarding this letter,please feel free to contact me at 704-734-0333.
Sincerely,
Edgar O. Murphre',-.
Mayor, City of Kings Mountain
Cc: NC DWR Mooresville Regional Office,Water Quality Permitting Section

Division of Water Resources
North Carolina(NC) eDMR Reports
eDMR Registration Form
EDMR is an electronic reporting system, which will provide a facility Owner the ability to submit
discharge monitoring reports via the internet. EDMR is only currently available to facilities that
have an NPDES Wastewater permit issued by the Division of Water Resources. Registration for
eDMR must be completed by the legal Owner of the facility(s), and this legal Owner must be the
same Owner to which the permit(s)have been issued. Once an Owner is registered for eDMR,all
permits held by the Owner will also be registered and able to submit reports via eDMR.
NOTE: Before completing and submitting the registration form, the legal Owners as specified
above should verify the permit facility, Owner, and ORC designations for all permits. This
information can be verified using the eDMR Owner Information Search provided on the
eDMR website. This information is maintained in the DWR data management system, as
provided by the permittee, and contained in the permit issued to the Owner. Should any
discrepancies with this information be determined, the appropriate DWR contact should
be notified so information can be corrected prior to registration. It is important that the
permit information be correct prior to eDMR rezistration.
Please provide all information in Parts A, B, C and D. An Owner signature is required for
eDMR registration. Should the registration information be incomplete,the registration
process may be delayed.
Part A: Owner Registration—Permit/Facility Information
Please provide a Permit Number and the associated facility information. Only a single permit
number is needed for registration. If multiple permits are involved,the permit number provided
will be used to identify the Owner and all associated permits. All associated permits issued to the
Owner will be registered for eDMR.
RECEIVED/DENRJDWR
Permit Number: N I C I 0 I 0 17 9 7 4 0 OCT 1 5 2014
Facility Owner: City Of Kings Mountain Water Quality Secti
Permitting Section
Facility Name: T.J. Ellison Water Treatment Plant
Facility Address: 1432 Oak Grove Rd
Facility City: Kings Mountain Facility State: NC
Facility Zip code: 28086-
NC eDMR Registration Form(Revision 3.1) Page I of 4

Part B: Owner Registration-Owner User Details:
Please provide the following information which is needed for creating the Facility Owner in
eDMR. The Owner is the legal entity to which the permit(s)have been issued and may be an
organization or individual. For an organization,the information provided for the owner details should
be the official contact person or the person with delegated signatory authority for the Owner.
Last Name: Wells
Middle Name: Ray
First Name: Dennis
Phone Number: 704-734-4525
Email: [e-mail]
User Id: (Assigned by DWR eDMR Administrator)
Part C: User Account Information—Submitters
Please provide the users,in addition to the Owner,who will need Submitter permissions.
Submitter permissions can only be assigned by the DWR eDMR Administrator. The Owner specified
above will be given full eDMR permissions including Submitter permissions.
The Submitter is equivalent to the individual who signs the certification statement on the back of the
discharge monitoring report. In most cases,the Submitter will be the Owner but may be other
delegated individuals. The Submitter must be an individual with delegated signatory authority. If
individuals other than the duly authorized person 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 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.
NOTE: The Owner will be responsible for creating all facility users except those with Submitter
permissions.
In addition to the Owner and Submitter user, there are four additional user types identified
by user permission level: Facility Administrator, Certifier,Data Entry and View Only.
The Owner and Facility Administrator will have the ability to manage facility users. The
Facility User Administration Guide will provide the appropriate procedures for facility user
management:
NC eDMR Registration Form(Revision 3.1) Page 2 of 4