NC0073571_Signature Authority_20231024

State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
INSTRUCTIONS FOR FORM: PNOCF 01-16
Division of Water Resources
I. EXISTING PERMITTEE INFORMATION:
RECEIVED
I. Permittee's name:Ii)ir,y1VA16-:rili:fiTiOCT 1 8 2023
2. Signature authority's name:Todd Nunn per 1 SA NCAC 02T.0106(b)
3. Signature authority's title:President and CEO NCDEQ/DWR/NPDES
4. Permittee's mailing address: 7700 US Hwy 158
City:Stokesdale State:NC Zip: 77357-
5. Permittee's contact information: Phone number.[phone] Fax Number( )_
Email Address: todd(a)compasshcr.com
II. APPLICANT INFORMATION:
C OtYlee
1. Applicant's name tota�d i lit�rrn ? 11, 11,47t10/7
1v000 351
2. Signature authority's name:Todd Nunn per 15A NCAC 02T.0106(b1
3. Signature authority's title: President and CEO
4. Applicant's mailing address: 7700 US Hwv 158
City:Stokesdale State:NC Zip: 27357-
5. Applicant's contact information: Phone number: [phone] Fax Number(_)_
Email Address: todd a compasshcr.com
6. Representative's name: Madelyn Mills,Envirolink,Inc.
7. Representative's title: Compliance Coordinator
8. Representative's contact information Phone number:[phone] Fax Number(_)
Email Address: mmills(li)cnvirolinkinc.com
III. PERMIT INFORMATION:
1. Existing permit number.NC0073571 and most recent issuance date: May 11,2021
2. Reason for the permit application: Select If other, attach detailed explanation
3. Has the facility been constructed? ®Yes or❑ No
4. Has the facility been certified per ISA NCAC 02T.01.16?- ® Yes or❑ No
FORM:PNOCF 01-16 Page 1 of 2

State of North Carolina
Department of Environmental Quality
DWR
Division of Water Resources
SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
This form is for ownership changes or name changes of a sewer system permit. Please note that"Permittee" references the
existing permit holder,and that"Applicant" references the entity applying for the ownership/name change.
Sewer permits start with a WQ or WQCS and contain the terms sewer extension or collection system in the subject field. This
form should not be used for permits with NC, NCG, SW or other types of non-sewer permits beginning with WQ.
For more information,visit the Division's Water Quality Permitting s website:
A. Sewer System Permit Ownership/Name Change (FORM: PNOCF 01-16)Application(All Applications):
El Submit an original completed and appropriately executed application(PNOCF 01-16).
O The Existing Permittee's Certification shall be signed in accordance with I5A NCAC' 02'I'.0106(b). Per I5A NCAC 02T
.0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from a person who
meets the criteria in 15A NCAC 02T.0106(b). ���
El The Applicant's Certification shall be signed in accordance with 15A NCAC 02T.0I06(h). Per Fiui, ' (Pd' 1Lt i(c),an
alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the crite is
in 15 A NCAC 02T.0106()t. 3
q
B. Existing Permit(All Applications): OCT 18 ZOG
® Submit a copy of the most recently issued permit and certification. �1
C. Property Ownership Documentation (All Applications): NCDEQ/DWR/NPDE
➢ ThrApplicant shall demonstrate they arc the owner of all property containing the sewer system facilities:
L}3/ Legal documentation of ownership(i.e.,GIS,deed,article of incorporation,or contract),or
❑ Written notarized intent to purchase agreement signed by both parties with a plat or survey map,or
❑ Approved board minutes
D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately-Owned Public Utility):
❑ Per 15A NCAC 02T .01 15(a)(I),provide one copy of the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served
by the non-discharge system.
E. Operational Agreements (Applications'where the Applicant is a I-lome/Property Owners' Association or Developer of lots to be
sold):
➢ Ilomc/Property Owners' Associations
❑ Per I 5A NCAC 02T.01 15(c),submit an original properly executed Opera tiona I Avreement(FORM: HOA).
❑ Per 15A NCAC 02T.01 15(c),submit an original proposed or approved Articles of Incorporation,Declarations and By-
laws that contain the language required by the Operational Agreement.
> Developers of lots to be sold
❑ Per 15A NCAC 02T.01 15(b),submit an original of the properly executed Operational Agreement(FORM: DEV).
F. Package Submitted in Duplicate
El Submit a copy of all required documents in Instructions A-E as required
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED IN DUPLICATE
TO:
NCDEQ -DWR
Water Quality Permitting Section
PERCS Unit
By U.S. Postal Service: By Courier/Special Delivery:
1617 MAIL SERVICE CENTER 512 N.SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1636 SUITE 925
RALEiGH. NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone]
INSTRUCTIONS FOR APPLICATION PNOCFO1-16 Page 1 of 1

IV. CERTIFICATIONS:
Existing Permittec's Certification per 15A NCAC 02T.0106(b): ^
C attest that this application
(Signature Authority's name&title from Application Item I.2 &3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of theperm it
into the Applicant's name,I will continue to be responsible for compliance with the current permit and any discharge of wastewater
from this system to surface waters or the land may result in an enforcement action that may include civil penalties,injunctive relief,
and/orcriminalprosecution. I will also make no claim against the Division of Water Resources should a condition of the existing permit
be violated. I also understand that if all required parts of this application are note completed and that if all required supporting
information and attachments are not included,this application will be returned to me as incomplete.
NOTE— In accordance with General Statutes 143-215.6A and 143-215.6B,any person who knowingly makes any false statement,
representation,or certification in any application package shall be guilty of a Class 2 misdemeanor,which may include a fine not to
exceed$10,000 as well as civil penalties p to$25,000 per violation.
Signature: C Date: 72—cf/Z 3
Applicant's Certification per 15A NC:1C 021'.0I 06(b)Y
I, / J`) " `'`""`. �`—e—e,,_-- f✓�P A f attest that this application
(Signature Authorit'sname&title from Application Item II.2&3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that a fterissuance of the permit into
the Applicant's name,I will be responsible for compliance with the issued permit and any discharge of wastewater from this non-
discharge system to surface waters or the land may result in an enforcement action that may include civil penalties,injunctive relief,
and/orcriminal prosecution. I will make no claim against the Division of Water Resources should a condition of this permit be violated.
I also understand that if all required parts of this application package are not completed and that if all required supporting information
and attachments arc not included,this application package will be returned to me as incomplete.
NOTE — In accordance with General Statutes.i43-215.6A and 143-215.613,any person who knowingly makes any false statement,
representation,or certification in any application package shall be guilty of a Class 2 misdemeanor,which may include a fine not to
exceed$10,000 as well as evil penalties up to$25,000 per violation.
Signature: !" Date: `3 Z?
FORM:PNOCF 01-16 Page 2 of 2

BILL OF SALE, ASSIGNMENT,AND ASSUMPTION AGREEMENT
THIS BILL OF SALE, ASSIGNMENT, AND ASSUMPTION AGREEMENT
("Agreement") is made as of this 16-0tiday of September, 2023, by and among Countryside
Properties I Limited Partnership, a North Carolina limited partnership ("Countryside
Properties"), and Countryside Manor, Inc., a North Carolina corporation ("Countryside
Manor') (Countryside Properties and Countryside Manor are referred to collectively as "Seller")
and Compass Really Guilford, LLC, a North Carolina limited liability company ("Purchaser").
WHEREAS, Seller and Purchaser are parties to an Asset Purchase Agreement dated
effective August 8, 2023, ("Asset Purchase Agreement"); all capitalized terms used but not
defined herein shall have the meanings attributed to them in the Asset Purchase Agreement; and
WHEREAS, pursuant to the Asset Purchase Agreement, among other things, (i) Seller
agreed to sell, transfer, assign, and convey to Purchaser, and Purchaser agreed to purchase, the
Assets; and (ii) Seller agreed to assign to Purchaser, and Purchaser agreed to assume, the
Assumed Contracts and Assumed Equipment Leases;
NOW, THEREFORE, in consideration of the promises and the mutual covenants and
agreements set forth in the Asset Purchase Agreement and this Agreement, the receipt and
sufficiency of which hereby are acknowledged, the parties agree as follows:
1. Transfer of Assets. Seller hereby sells, transfers, assigns, and conveys to
Purchaser, its successors and assigns, and Purchaser hereby purchases and
acquires from Seller, all of Seller's right, title, and interest in and to the Assets,
but excluding the Excluded Assets, pursuant to and subject to the provisions of
the Asset Purchase Agreement.
2. Assumption of Assumed Contracts and Assumed Lease. Seller hereby transfers
and assigns to Purchaser, and Purchaser hereby assumes, any Assumed Contracts
and Assumed Equipment Leases effected under this Agreement, and all
obligations of Seller thereunder, but excluding the Retained Liabilities, pursuant
to and subject to the provisions of the Asset Purchase Agreement. Purchaser
hereby agrees to pay, satisfy, perform, and fully discharge the obligations, debts,
and responsibilities under the Assumed Contracts and Assumed Equipment
Leases arising after the date hereof, and Purchaser shall defend, indemnify, and
hold harmless Seller, their successors and assigns, from and against any and all
liabilities, obligations,claims, damages, costs, and expenses (including court costs
and reasonable attorney fees) related to or arising from Purchaser's failure to fully
perform and discharge its responsibilities pursuant to this Section.
3. Confirmatory Instruments. Seller and Purchaser hereby mutually covenant and
agree that they will execute, deliver, and perform, as applicable, any and all
further acts, instruments, transfers, assignments, conveyances, assurances, and
filings that may be reasonably requested by Seller or Purchaser to accomplish the
purposes and benefits of this Agreement.

IN WITNESS WHEREOF, the duly authorized officers of the parties hereof have
executed this Agreement in manner and form so as to be binding as of the date stated above.
SELLER:
Countryside Properties I Limited Partnership,
a North Carolina limited partnership
By: tr22//,-��
VA X 4/f
(Printed Name/Title)
Countryside Manor, Inc.,
a North Carolina corporation
By:
y 44/. (14e44-C211
(Printed Name/Title)
PURCHASER:
Compass Realty Guilford,LLC,
a North Carolina limited liability Company
By: o-��t2 4.1
Tod W.Nunn.its Manager
Page 3

I.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/Organization Name: Countryside Manor
Responsible Official: Todd Nunn
(as identified in accordance with 40 CPR 122.22)
Street Address: 7700 US Hwy 158
City: Stokesdale
State/Zip: NC 27357
Phone Number: (919)9224084
Email Address: tcticcompassnrreem
*email will be the primary method of contact for the electronic C
submittal process so it is important to have an accurate email -0 d) Cj `J\ ( p`'SS vZ C/-
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 Submitter(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

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 NCDWR's approved system
for electronic submittals in lieu of paper submissions.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.
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 violations,Civil Penalty
Assessments,and any other correspondence related to compliance with federal and state water quality
laws and regulations that might be sent by 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.
5. Agree to protect both the electronic signature credential,consisting of my user name 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 name or
password has been modified.
8. Understand that eDMR reports the last date my user name and password were used immediately after
successfully logging into eDMR.
9. Agree to contact the NCDWR eDMR Administrator via email at eDMRadmin(c�ncdenr.gov as soon
as possible,but no later than 24 hours, after suspecting or determining that my user name and/or
password have become lost, stolen or otherwise compromised.
10. Agree that 1 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
NCDWR's 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 NCDWR eDMR Administrator via email at [e-mail] if I 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 NCDWR eDMR Administrator via email at [e-mail] as soon as
possible, but no later than 24 hours, after receipt.
NCDWR Electronic Submittal Agreement Version 1 Page 2

•
•
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 ellMRadmin(rrtjiede rj oy.
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 eDMItndntin(u,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 cDMRadmin@ncdenr.,,oy 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 1 have the authority to enter into this Agreement on behalf of the Organization identified
above,and 1 am a signatory authorized to represent that Organization,and 1 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
Number' Facility Name "Facility Address. . Submitter2(if applicable)
NC0073571 Countryside Manor 7700 US Hwy 158 Madelyn Mills
W WTP
Todd Robinson i
Rebecca Manning
Joshua Powers •
•
I. 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:hntps://deq.nc.t!ov/about/divisions/water-
resourees/edmr/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 .1

D. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 1222.22, is the appropriate individual
with the authority to sign and submit reports for the organization.
1, Todd Nunn (printed name),have the authority to enter into this
Agreement for Countryside Manor (Owner/Organization Name).
I request the NCDWR grant me and, if included in Sections C and E of this form, the named Submitter(s),
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 Sections C and E(if applicable),work at/for 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,_ Todd Nunn (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.
rc/ a / 7 2� /
Responsible Official Signature itle // D to
Todd( compasshcr.com 14 CO y //.? ( J O
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 23 day of •u It/ , 2021
7'17/64
Signature of Notary Public
Mrs N Riersp ,
rtAISTI N RIERSON Printed Name of Notary Public
NOTARY PUBLIC
R0VinINGHAM COUNTY,NC
My Commission Expires 10.12-2P25 My Commission Expires: f D• r<2• Zb 25
(SEAL)
NCDWR Electronic Submittal Agreement Version 1 Page 4

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.
I, Madelyn Mills ,am authorized by the Responsible Official
name in this document,who does have the authority under the applicable standards, to enter into this
agreement for Countryside Manor
By submitting this application,1, Madelyn Mills ,have read,
understand,and accept the terms and conditions of this Electronic Signature Agreement.I certify under
penalty of law thatI 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.
7/15/2—
Compliance Coordinator
Submitter Signature Title Date
mmills(a,envirolinkinc.com 984-365-9160
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 1 day of , 2021 •.
1,
\\01unJJriiiiii •
..r...r,,, ' Signatu Notary Public
r� ,(i AY
U =
.G { = et kid 14„,„
r� •.,P a` � Printed Name of Notary Public
My Commission Expires: a—J r D a.LI
(SEAL)
I signed this notarial certificate on July 13,2021 according to the emergency video notarization
requirements contained In G.S.10B-25.
Notary Public location during video notarization:Wake County
Stated physical location of principal during video notarization: Buncombe County
NCDWR Electronic Submittal Agreement Version 1 Page 5

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.
I, Todd Robinson ,am authorized by the Responsible Official
name in this document,who does have the authority under the applicable standards,to enter into this
agreement for Countryside Manor
By submitting this application,I, Todd Robinson ,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
Assistant Area Manager 7//.3" /
Submitter Signature Title Date
trobinson(ienvirolinkinc.com 252-235-8809
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 (3 day of J UJL1 ,2021
alit II fill///il IA 1,0 unt�l'LQ.,✓3
-•" ' �r � Signatur fNotaryPublic
•�v 'rL0Til� Li
• (�l3 L(C ��1 LLI b V►� • V bo k_m
••. ....••' �\ Printed Name of Notary Public
My Commission Expires: 0
(SEAL) I signed this notarial certificate on July 13,2021 according to the emergency video notarization
requirements contained in G.S.10B-25.
Notary Public location during video notarization:Wake County
Stated physical location of principal during video notarization: Davie County
NCDWR Electronic Submittal Agreement Version 1 Page 6

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.
I, Rebecca Maiming (printed name), am authorized by the Responsible
Official name in this document,who does have the authority under the applicable standards,to enter into
this agreement for Countryside Manor (Owner/Organization Name).
By submitting this application,I, Rebecca Manning (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.
-1 1C/I,.0,,(1 1 (,1(�'�1Y Compliance Coordinator 7/13/2021
Submitter Signature Title Date
[e-mail] 984-365-9155
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: rmanning rr envirolinkinc.com
User Id
Subscribed and sworn to before me this 3 day of G kitr/ , 2021.
``���lllllllffl/1!t/tt` gyp•L`
Signatur ofNotary Public
7 ••''UBL0C :cj` G(;2�-be W. Uillk.t'ns
�'>}•'••..,,••,.••' Printed Name of Notary Public
lOjfUll111,\\\\\`�`
My Commission Expires: 69—1 La`aU0--1
(SEAL)
NCDWR Electronic Submittal Agreement Version 1 Page 7

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.
I, Joshua Powers (printed name), am authorized by the Responsible
Official name in this document, who does have the authority under the applicable standards,to enter into
this agreement for Countryside Manor (Owner/Organisation Name.
By submitting this application, 1,- Joshua Powers (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, inc . e possibility of fine and imprisonment.
Area Manager p.9 P-d Owl
mi r Signature Title D to
jpowers cr envirolinkinc.com 704-775-6128
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: [e-mail]
User Id
Subscribed and sworn to before me this ZZ day of },,t.k.f 2021.
Signatu e of Notary Public
�ZO
c\a Z 1.0 .1' Cl IiC�I 1" OU)'
Z • 0 :if — Printed Name of Notary Public
}
..........
.O�% My Commission Expires: �C� -2-
alli
(SEAL)
NCDWR Electronic Submittal Agreement Version 1 Page 8