NCG120040_SW Permit DOSA (2)_20230306

NC Department of Environmental Quality
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Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Em ronmental Quality
Stormwater eDMR Submitter Change Request Form
=> This form is for adding or updating the Submitter User(s). Submitter(s) must have
signatory authority for the permit in order to have Submitter privileges in eDMR.
A. Owner Information
=> This form must be completed by a Responsible Official who meets the legal signature
authority requirements in 40 CFR 122.22 or a person who has been delegated
signature authority to act on behalf of the Owner.
Owner/Organization Name: I Halifax Cou
Responsible Official Name: Dla Denton
Title: County Manager
eDMR User ID:
Email Address: [e-mail] I Phone: [phone]
Mailing Address: 10 N King St
City: Halifax I State: INC I zip: 127839
B. Activate New Submitter or Update Existing User
=> Please complete the Submitter User Detail on page 2 for the individuals who will need
Submitter permission or to update Submitter details, such as adding additional permits,
to an existing user. Submitter permissions can only be assigned by the Stormwater
eDMR Administrator. Note: The Responsible Official and Facility Administrator
can deactivate or delete eDMR user permissions for any individual within its
organization, including Submitter permissions.
=> 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 user and/
or permits, please make additional copies for the Submitter User Details page and
complete as needed.
eDMR Submitter Change Request Form
Page 1

Submitter User Details
Permit No. (s): NCG120040
First Name: .Jesse
Middle Name:
Last Name: U
Phone Number:919-828-0577 ext.170
Email: [e-mail]
Select Request ✓Add User Permission
Type: , ❑ Update User Permission
Permit No. (s):
First Name:
Middle Name:
Last Name:
Phone Number
Email:
IUser ID: [e-mail]
(Assigned by NCDWR eDMR Administrator)
Submitter User Details
Select Request UAdd User Permission
Type: Update User Permission
Permit No. (s):
First Name:
Middle Name:
Last Name:
Phone Nun'
Email:
Select Request
Type:
User Permission as of (Date:
User I
(Assigned by NCDWR eDMR Administrator)
;e User Permission as of (Date;
Submitter User Details
Add User Permission
Update User Permission
User ID:
(Assigned by NCDWR eDMR Administrator)
User Permission as of (Date
eDMR Submitter Change Request Form
Page 2

C. Electronic Signature Agreement Conditions
To receive and accept the required electronic signature credential, consisting of a User ID and
password, issued by the North Carolina Division of Water Resources (NCDEQ) in order to sign
electronic documents submitted to NCDEQ's Electronic Document Systems and to receive
electronic documents from NCDEQ's systems;
The Responsible Official and Submitter(s) (if applicable) named in this form do herby:
1. Understand that this Electronic Signature Agreement requires me to submit electronic
documents to NCDEQ'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
NCDEQ. This authorization will not become effective until NCDEQ establishes a system for
processing electronic documents; I am notified in writing from NCDEQ 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.
3. Understand that this Electronic Signature Agreement requires me to submit electronic all
necessary information for processing of NPDES application including information for renewal of
existing permits, modification to existing permits, and applications for new discharge permits.
The submittals may include all necessary applications and supporting documentation to
NCDEQ's approved system for electronic submittals in lieu of paper submissions. This
authorization will not become effective until NCDEQ establishes a system for processing
electronic documents; I am notified in writing from NCDEQ 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.
4. Understand that this Electronic Signature Agreement requires me to accept electronic
submissions, in lieu of paper submissions, of all Notices of Deficiency, Notices of Violation, Civil
Penalty Assessments, and any other correspondence related to compliance with federal and
state water quality laws and regulations that might be sent by NCDEQ. This authorization will
not become effective until NCDEQ establishes a system for processing electronic documents;
am notified in writing from NCDEQ 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.
5. Agree to protect both the electronic signature credential, consisting of my User ID and
password, and security questions and answers, from compromise and from use by anyone
except me. Specifically, I agree to maintain the secrecy of my electronic signature credential
and security questions and answers; I will not divulge or delegate my credential or security
questions and answers to any other individual; I will not store my credential or security
questions and answers in an unprotected location; and I will not allow my electronic signature
credential or security questions and answers to be written into computer scripts to achieve
automated log -in.
6. Understand and agree that I will be held as legally bound, obligated, and responsible for the use
of my electronic signature as I would be using my hand-written signature.
7. Understand that I will be informed through my registered email address whenever my User ID
or password has been modified.
eDMR Submitter Change Request Form
Page 3

8. Understand that eDMR reports the last date my User ID and password were used immediately
after successfully logging into eDMR.
9. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMR Wncdenr. ov as
soon as possible, but no later than 24 hours, after suspecting or determining that my User ID
and/or password have become lost, stolen or otherwise compromised.
10. Agree that I will review the contents of all electronic submissions prior to submission.
11. Understand that I will automatically receive an email receipt at my registered email address
from the NCDEQ's SW-eDMR system for any submission that contains a valid electronic
signature, identifying the document received, the signatory, and the date and time of receipt.
12. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMRancdenr.gov if
do not receive an email receipt as specified above within five (5) business days for any
electronically signed submission using my credentials.
13. Agree that if I received an email notification for an activity that I do not believe that I performed,
I will notify the NCDDEQ SW-eDMR Administrator via email at [e-mail] as soon
as possible, but no later than 24 hours, after receipt.
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 NCDEQ eDMR has received
from me by contacting the NCDEQ SW-eDMR Administrator via email at SW-
eDMR(@,ncdenr.gov.
15. Understand that the NCDEQ 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 NCDEQ SW-eDMR Administrator via email at SW-eDMR ncdenr. av
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 NCDEQ SW-eDMR Administrator via email at SW-eDMR(a-),ncdenr.goy 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 NCDEQ 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.
eDMR Submitter Change Request Form
Page 4

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.
Dia Denton
this Agreement for Halifax Cou
(printed name), have the authority to enter into
(Owner/Organization Name).
I request the NCDEQ grant the Submitter(s) named in Part B of this form an electronic signature
credential to submit and accept documents electronically on behalf of my organization.
I acknowledge that I, and the individual(s) named in Part B of this form, work at/for my
organization and have authority to submit and accept electronic documents and act as a
signatory for purposes of the NCDEQ's electronic document systems.
By submitting this application, I, Dia Denton (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.
Responsible Official Signature
Title
eDMR Submitter Change Request Form
Page 5
lz 2
Date

E. Submitter Signature
=> Provide a separate page of Part E for each Sumitter User listed in Part B.
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.
Jesse Li
(printed name), am authorized by the
Responsible Official named in this document, who has the authority under the applicable
standards, to enter into this agreement for Halifax County (Owner/
Organization Name).
By submitting this application, I,
Jesse Li
(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.
Submittrr-Signature
0A 0, 1 AAt-e
Title
3 /6 / IX-3
Date
Submit the completed Stormwater eDMR Submitter Change Reguest Form in hard co
with original signatures to:
DEMLR Stormwater Program eDMR
Attn: Stormwater eDMR Administrator
1612 Mail Service Center
Raleigh, NC 27699-1612
eDMR Submitter Change Request Form
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