NC0051608_eDMR Registration Form_20160819

WatcrResources
ENVIRONMENTAL OJAtITY
Part A. PERMIT/FACILriY INFORMATION
State of North Carolina
Department of Environmental Quality
Division of Water Resources
EDMTR REGISTRATION'FORIM
1. NPDESLPermit Number: N I C 1 0 10 G
2. Owner/Organization Named:,, CAAg Ob'j C -O `n' - Y S j,00\ S
-3. Facility Name: ecv�q (,Wbq CG�41-\�-x
4. Facility's Physical Address: 2-S 00 Parte kye
City: Pew�011 State: NC Zip Code: ZOL579
Part B. OWNER USER INFORMATION
1. Responsible Official's Name: �� C�.� Title:
(Owner or duly authorized representative)
2. Mailing Address: . Q O N36 .x 1010
City: Wle-wk& V\ State: P C. Zip Code: ZG (Srb
3. Telephone Number: 2� 9 -315 C 2
4.. Email Address:
5. User ID (Assigned by NCDWR eDMR Administrator):
PartC. USER ACCOUNT INFORMATION
1. Facility.Administrator Permission
The Facility Administrator user permission can be assigned at the time of registration by the NCDWR
eDMR Administrator. If someone other than the Owner will be responsible for managing facility users
within eDMR and you would like the Division to set up the permission at the time of registration, then
please provide the user details for the individual who will need the Facility Administrator user permission.
Note: If this person will bexesponsible forsubmitting eDMR reports, then you will also need to request
Submitter permission for this user.
In addition to the user details, please specify the permit number(s) to which the user will be associated. If
additional space is needed, please make additional copies of the Facility Administrator User Details and
complete as needed..
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°Fatuity Ad[rihistrator Wer De - -1 ,
Per`mrENo:(s) �{COOSEGO0 NCOO 7gZ3.30Cc>a2aZA-7j�iGcon(,3Gy
First Name:.:
Mic[dle Name
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SLast Name::
Phone Number _ 3<62
Elan User 117 �
C'iCk SQi Calaw6c5ehcviS. (Asslgned6yDWReDIVIRAdminist�dtor) r
NC eDMR Registration. Form (Revision 4.1)
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