NCG060158_SW Permit DOSA_20240207

NC Department of Environmental Quality
f Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental Quafdty
Stormwatere eporting egistrationr
Directions are in red.
Completion of the Stormwater Electronic Reporting (eReporting) Registration Form is a
required step for the Owner and, if applicable, other User Account(s) to obtain the privilege of
submitting electronic reports to DEQ and in lieu of submitting paper reports.
In addition, this form allows for Owners to designate Facility Administrator(s) and Submitter(s)
who can act on their behalf. Owner and User(s) must agree to the Electronic Signature
Agreement (ESA) Conditions contained in this form.
A. Owner Information
The Owner is the legal entity to which/whom a permit has been issued. The Owner may be an
individual or organization. Every Owner is required to have a Responsible Official who meets
the legal signature authority requirements in 40 CFR 122.22.
• For a corporation, this individual shall a president, secretary, treasurer, or vice-president in charge of
a principal business function, or another individual who performs similar functions for the corporation,
or the manager of one or more manufacturing, production, or operating facilities who is authorized to
make management decisions about the facility operation.
• For a partnership or sole proprietorship, this individual shall be a general partner or the proprietor,
respectively;or
• For a municipality, State, Federal, or other public agency, this individual shall be either a principal
executive officer or ranking elected official,
Owner Name: Mennel Milling&Bakery Mix of North Carolina LLC Title: Director of EHS
Responsible Official Name: Brendan Coughlan Phone: [phone]
Does the Responsible Official Yes r No If Yes,
already have an eDMR account? User ID:
Email Address: brendancoughlan [e-mail]
Mailing Address: 319 S Vine St
City: Fostoria State: OH zip: 44830
Stormwater Electronic Reporting Registration Form
Page 1

B. Permit Information
Include all stormwater permit currently held by the Owner(both Individual and General
permits). Designate any applicable users for each permit. Attach additional pages if you need
more space.
Permit No. Facility Name Facility Address Name of the User
(if applicable)
NCG060158 MennelMilling&BakeryMix-Newton 324 East A St Brendan Coughlan
NCG060158 MennelMilling&BakeryMix-Newton 324 East A St Adam Campbell
Stormwater Electronic Reporting Registration Form
Page 2

C. User Account Information
Include the following information for all User(s) listed in Part B. Attach additional pages if you
need more space.
Click on one or more of the two access roles available: Facility Administrator and/or
Submitter.
® if the user enters data and submits report on behalf of the facility, then the Submitter
role should be requested. This role is automatically approved to enter and certify the
data. This person must have signatory authority for the permit.
® If the user is the person responsible for managing user information for the facility/permit,
then the Facility Administrator role should be requested. The Facility Administrator
user can be assigned by the Responsible Official or can be assigned at the time of
registration by the Stormwater eDMR Administrator. Note: If this person is responsible
for submitting eDMR reports, then they must have signatory authority for the permit.
User Account Information Permit Number(s) NCG060158
Request Access Role: ❑✓ Submitter ❑✓ Facility Administrator
Name: Brendan Coughlan Title: Director of EHS
Do you already have an eDMR Yes ❑✓ No(User If I Phone: [phone]
account? [User ID
Organization: The Mennel Milling Company
Email Address: [e-mail]
Mailing Address: 319 S Vine St
City: Fostoria State: OH Zip: 44830
User Account Information Permit Number(s) NCG060158
Request Access Role: Submitter ❑✓ Facility Administrator
Name: Adam Campbell Title: EHS Coordinator
Do you already have an eDMR If Yes, 980-391 -1384
✓ No
account? ❑Yes User ID Phone:
Organization: The Mennel Milling Company
Email Address: [e-mail]
Mailing Address: 11 N Brady Ave.
City: Newton State: NC Zip: 28658
User Account Information Permit Number(s)
Request Access Role: QSubmitterFacility Administrator
Name: Title:
Do you already have an eDMR ❑ ❑ If Yes, Phone:
account? Yes No User ID
Organization:
Email Address:
Mailing Address:
City: State: Zip:
Stormwater Electronic Reporting Registration Form
Page 3

D. 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 Department of Environmental Quality (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 other User Account(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; 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.
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.
Stormwater Electronic Reporting Registration Form
Page 4

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(c�deq.nc.gov 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-eDMR(cr)deq.nc.gov 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
performed, I will notify the NCDDEQ SW-eDMR Administrator via email at SW-
eDMR(c�deq.nc.gov 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-eDMRPdeq.nc.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-eDMRRdeq.nc.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 NCDEQ SW-eDMR Administrator via email at SW-eDMR{a�deq.nc.gov if
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.
Stormwater Electronic Reporting Registration Form
Page 5

F. User Signature
Provide a separate page for every User listed in Part B.
This form must be completed with an original wet signature (not digital) 140 CFR
122.22]
Users other than the Responsible Official who can submit this agreement to request to sign
reports electronically and other information and to accept electronic documents.
1, Brendan Coughlan (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 Mennel Milling & Bakery Mix of North Carolina
(Owner/Organization Name).
By submitting this application, I, Brendan Coughlan (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.
ram/ -"7- .
Director of EHS 2/7/2024
User Signature Title Date
eDMR User ID
Submit the completed Stormwater Electronic Reporting Registration Form in hard copy
with original signature to:
DEMLR Stormwater Program eDMR
Attn: Stormwater eDMR Administrator
1612 Mail Service Center
Raleigh, NC 27699-1612
Stormwater Electronic Reporting Registration Form
Page 7

E. Responsible Official Signature
This form must be completed with an original wet signature (not digital) [40 CFR 122.221
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.
I Brendan Coughlan (printed name), have the authority to enter
into
this Agreement for Mennel Milling&Bakery Mix of North Carolina LLC (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.
pp Brendan Coughlan (printed name),
By submittingthis application, I,
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.
/
X:z.-cz-Z---- __.-1.--- - ------
/' Director of EHS 2/7/2024
Responsible Official ignature Title Date
eDMR User ID
Stormwater Electronic Reporting Registration Form
Page 6

t.
ROY COOPER
Governor 't�
ELIZABETH S.BISER 81 '
Secretary
DOUGLAS R.ANSEL NORTH CAROLINA
Interim Director Environmental Quality
Stormwater Delegation of Signature Authority Form (DOSA)
This form shall be used to delegate signature authority from the permit Owner(Permittee) to
another party. Only the Responsible Official defined below may submit permit applications and
reports required by the permit (such as Data Monitoring Reports and Annual Reports) until this
form is completed and submitted to the DEMLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility and compliance for
permit compliance.
Permit Owner:The legal entity to which/whom a permit has been issued and may be an individual
or an organization such as a company or government agency. Every Owner is required to have a
Responsible Official who meets the legal signature authority requirements in 40 CFR 122.22,
summarized below:
• For a corporation,the Responsible Official shall be a president,secretary,treasurer,or vice president
in charge of a principal business function,or another individual who performs similar functions for
the corporation,or the manager of one or more manufacturing,production,or operating facilities
who is authorized to make management decisions about the facility operation.
• For a partnership or sole proprietorship,the Responsible Official shall be a general partner or the
proprietor,respectively;or
• For a municipality,State,Federal,or other public agency,the Responsible Official shall be either a
principal executive officer[City/County Manager]or ranking elected official[Mayor].
Please mail the DOSA Form with original wet signatures to: NCDEMLR Stormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity
Mennel Milling & Bakery Mix of North Carolina LLC
Responsible Official Name
Brendan Coughlan
Responsible Official Title:
Director of Environmental Health & Safety
Email Address: ' Phone
[e-mail] 419-7 31-57 8 9
Mailing Address
319 S Vine St
City State Zip code
Fostoria OH 44830
North Carolina Department of Environmental Quality i Division of Energy.Mineral and Land Resources
111"? d) 512 North Salisbury Street 11612 Mail Service Center I Raleigh.North Carolina 27699-l6I2
s nmr;rcmmerot Ewieorrmmass at, 919.707.9200

A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Attach additional pages if you need more space.
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address: Phone
Mailing Address
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address: Phone
Mailing Address
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address: Phone
Mailing Address
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 2

B. 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.
As the Responsible Official,I, Brendan Coughlan (printed name),
have the authority to enter into this Agreement for
Mennel Milling & Bakery Mix of North Carolina LLC (Owner/Organization Name).
I request that the DEMLR Stormwater Program include the persons listed in Part A of this
form signatory authority for the above-named permit.
I acknowledge that I,and the persons listed in Part A of this form work at/for my
organization and have authority to act as a signatory for purposes of the NCDEQ's
electronic document systems.
By submitting this application,I, Brendan Coughlan (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
-,-1/
-/ze= ,- ,.-,—_ . //
Responsible Official Signature
Director of Environmental Health & Safety 2/7/2 02 4
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3