NC0020389_Delegated Authority_20240918

September 12, 2024
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
RECEIVED
i8
1617 Mail Service Center
Raleigh, NC 27699-1617 NCDEQ/DWR/NPDES
Subject: Delegation of Signature Authority
BENSON WASTERWATER TREATMENT FACILITY
NPDES Permit Number NCO020389
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
the subject facility as required by all applicable federal, state, and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 213.0506.
Individual #1
Individual #2 (fapplicable)
Name:
Salvador Valdiviezo Jr.
Brian P. Leavitt
Title:
Superindentent For Waatewater Dept.
Operator
Mailing Address:
303 E. Church St.
Benson, Nc 27504
303 E. Church St.
Benson, Nc 27504
Physical Address:
(ifdifferenr)
770 Hannah Creek Rd.
Four Oaks, Nc 27524
770 Hannah Creek Rd.
Four Oaks, Nc 27524
Email Address:
[e-mail]
[e-mail]
Office Phone:
919 - 894 - 2373
919 - 894 - 2373
Mobile Phone:
984 - 301 - 4521
919 - 902 - 9599
If you have any questions regarding this letter, please feel free to contact me at
[e-mail] or 919-894-3553.
Sincerely,
Kimberly Pickett
Town Manager For Town Of Benson
303 E. Church St. Benson, NC 27504
[e-mail]
919-894-3553
252-916-7525
cc: Raleigh Regional Office, Water Quality Permitting Section

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
TAB to Navigate Form
Facility Name: BENSON WASTEWATER TREATMENT FACILITY Permit #
Facility Type: WW
Permittee Owner/Officer Name: Ki
Email Address:
Permittee
Facility Grade: IV
Pickett
NCO020389
SUBMIT A SEPARATE FORM FOR EAClI CLASSIFICATION
ORC
Operator in Responsible Charge
Date: C) l t 3' Zq
Full Name: Salvador Valdiviezo Jr. Work Phone: [phone]
Email Address: svaldiviezofttownofbenson corn
Certificate Type: WW _ Certificate Grade: IV---- Certificate #: 1009190
Signature: fif Effective Date: / QCK
'I certify that 1 agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in ISA NCAC 08G .0204 and
failing to do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.'
Backup ORC
Full Name: Brian Peter Leavitt Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 1007659
Signature: 2 Effective Date: et //t/L y
'I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G.0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.'
Backup ORC "
Full Name: Steve A. Procter Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: % 26527
Signature: cl�, A & � Effective Date: l 1
certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. 1 understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and falling to do
so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.'
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 1 FAX: [phone] [e-mail]
Mail or fax a COPY to: Choose DWR Regional Office that has coverage of this facility.
Revised 1r1019

� STATI O
N.C. Department of Environmental Quality
Division of Water Resources
•.tea;,;;,.•
Electronic Signature Agreement
' NORTH CAROLINA
Instructions and Submittal Form
EnWranmcmal Quality
This form is used to request that the N. C. Division of Water Resources (NCDWR) grant electronic
signature credentials to the individuals outlined in the form for NPDES wastewater permittees. The
Electronic Signature Agreement (ESA) must be submitted in hard copy form with original notarized
signatures for each individual requesting the credentials. For the most recent version of this form
please check NCDWR's website at: https:/Ideg.nc.gov/about/divisions/water-resources/edmr/forms-and-reports
Please use the following instructions as a checklist to ensure that all required information is included.
Following these instructions will help provide a quicker review time and reduce the need for additional
information requests.
❑ Section A. Owner / Organization Information
Provide the Owner / Organization information requested. The Owner is the legal entity to which
permits have been issued and may be an individual or organization.
This section requires a Responsible Official. For an organization the information provided
should be the person with legal signature authority in accordance with 40 CFR 122.22.
This section requires an email address for the responsible official. Email will be the primary
contact method so you must assure that any changes or updates to email addresses are
provided to NCDWR in a timely manner.
❑ Section B. Agreement Conditions
Please read these conditions carefully as they outline the terms of the electronic submittal
credentials.
❑ Section C. Permit/Facility Information
Provide information on the facilities and wastewater NPDES permits associated with the Owner/
Organization indicated in Section A of the.form. If you need more space a supplemental page
that may be used and attached is available on our eDMR website at:
httos://dea.nc.eov/a bout/divisions/water-resources/edmr/forms-a nd-reports
If there will be a document submitter other than the responsible official, then please indicate
the individual's name in this section in the last Column.
❑ Section D. Responsible Official Signature
Provide the information, signature and notarization for the responsible official as designated
throughout the form.
You must return this section with original signatures, copies will not be accepted.
A responsible official will be granted electronic submittal credentials even if other submitters
are included, in the form.
❑ Section E. Submitter Signature
If you are only requesting electronic submittal credentials for the responsible official, then you
do not need to complete Section E.
Instructions Page i

If you are requesting electronic submittal credentials for one or more individuals other than the
responsible official, then those individuals must be included in Section C with the
permits/facilities they will have electronic responsibilities for.
NCDWR must be notified in writing of delegations of signature authority. If you are providing
information for a Submitter that does not already have documentation of this authority on file
with the NCDWR then you may be asked to provide this documentation
You must include the Section E Submitter Signature page for each submitter listed in Section C.
Provide the information, signature and notarization for the submitter as designated.
You must return this section with original signatures, copies will not be accepted.
❑ Questions
If you have any questions about the NCDWR ESA submittal process, please contact us at:
Phone: [phone]
Email: [e-mail]
❑ SUBMIT COMPLETED FORM TO:
Information Processing Unit
Attn: Electronic Signature Agreements
1617 Mail Service Center
Raleigh, NC 27699-1617
Instructions Page ii

N.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:
Ink w'\
ResponsibleOfficial:
as identified inn accordance with 40 CFR 122.22
�\��� 7 �i�
Street Address:
30
City:
DA
State / Zi •
1JG
Phone Number:
qiq e�LA 21
Email Address:
*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
, , s� ( y p}� } �� �](� 1D1 ,
�.I V" �' --" - m
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:
I. 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

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 eDMRadminna,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 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
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 eDMRadmin(@,ncdenr.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 I performed, I
will notify the NCDWR eDMR Administrator via email at eDMRadmin(ancdenr.eov 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 eDMRadminna.ncdenr.Rov.
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 eDMRadmin(nedenr.nov 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 eDMRadmin(@cn denr.gov 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 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.
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
Numbers
Facility Name
Facility Address
Submitterx (if applicable)
NC0o10389
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Fool D..k5'. PVC
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1. 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: httns:/Ideo.naeov/about/divisions/water-
resources/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

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.
Agreement for
(printed name), have the authority to enter into this
(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, (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
Email Address
Title
Phone Number
Date
"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:
Subscribed and swom to before me this day of
(SEAL)
User Id
Signature of Notary Public
20
}'rioted Name of Notary Public
My Commission Expires:
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, � IyoJo % V Gi l Vj e29(printed name), am authorized by the Responsible Official
name in this document, who does have the authority and t e applicable standards, to enter into this
agreement for ftwA �✓aS�i wa �tl �ff to t /i 4Y (Owner/Organization Name).
By submitting this application, I, Say/e( VA WhVI',EZO : (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.
Submitter Signature Title Date
73
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 � day of �kAAe f(\W f , 20_aLL.
60'& M. '�a Aov\
Signature of Notary Public
)N\qe o. M-Nlf\:6n
Printed Name of Notary Public
My Commission Expires: 1'A - as a !s
(SEAL)
ANGELA is M.THORNTON
Notary Public, North Carolina
Johnston County
My m 'ss'on xpires
NCDWR Electronic Submittal Agreement Version 1 Page 5