NCG080907_Owner Affiliation Change_20240126

E. 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.
Daniel J.Brake (printed name), have the authority to enter into
this Agreement for Greenwood Motor Lines, Inc. (Owner/Organization
Name).
I request the NCDEQ grant me and, if included in Part B of this form, the named User(s), an
electronic signature credential to submit and accept documents electronically on behalf of my
organization.
I acknowledge that I, and if included in Part B of this form, the named User(s), 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, Daniel J. Brake (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 enalties for submitting false information, including the possibility of fine
Laninprisonme .
`jj L. Vice President 1 /24/2024
Responsible Offic.al Signature Title Date
eDMR User ID
Stormwater Electronic Reporting Registration Form
Page 6