NC0035904_Delegated Authority_20180705

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Date: 7/51 1 '
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority ,
Facility Name: NeDPS:McCain Co rrec.4i'c 161 Hospi t�C INWT P
NPDES Permit Number: NI C 1010 13 I5 IR 10 i41
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 2B.0506.
Individual #1 Individual #2 (if applicable)
Name: tkLir)e5( PaLeL
Title: C i V;l/Env.Eny y9 . Mn/y. RECEIVED/DENR/DWR
DF's-Centra.t E09ineer.'03
Mailing Address: 4216 MSG JUL 10 2018
Ra LeijM,l,1c 2769`'1= 11-21
Physical Address: N CD PS- ce n tra ld,En9 i+gee tt Water Resources
(if different) 2 d 2.0 yo h ke r4,RN• 2 76O 4, Permitting Section
RefEmail Address: 71a;nesl,pee(@Mcdps •go✓
Office Phone: (11q) 324 , /1-433
Mobile Phone:
If you have any questions regarding this letter, please feel free to contact me at either the phone
number or email address below.
Sincerel
hi. (9
A •rt d ging Official's Signature
delft-eV T. 0C3r avl€ Direckot; Ceofal EvIji iieev;v�
Authorized Signing Official's Name (type or print) Title
NCDPS-Ceriya.( En5ineertr►9 , 4216 MSG/ gale i5I , Nc 27699 -42 16
Mailing Address
je1fey • obrianf @ y)cdps . .30v
Email Address
(CO 324 - 1238
Office Phones ;31,, Mobile Phone
Ret.a_LeRegional Office, Water Quality Permitting Section
(Enter region name)

DWR
Submitter Change Request Form - (Add/update users)
• North Carolina Electronic Discharge Monitoring Report System
Division of Minter Resources -�r--
EDMR registered Owners may use this form to add or update eDMR users to the NCDWR's Electronic
Discharge Monitoring Report system. If the Organization is not currently registered for eDMR,then the
Owner or designated Responsible Official will need to complete the required eDMR Registration Form
(available from the eDMR website) and submit it to the NCDWR eDMR Administrator at the address
below.
Typeof Request (please select):
("_d' ' Add Submitter Permissions: (See Section B)
Update Submitter Permissions: (See Section B)
To add or update eDMR user permissions,please provide the following information:
Section A: Owner Information
NPDES Permit Number: J'1G 0635 C104-
Owner
o4-Owner/Organization Name: /QC - pt.• c4 Pu 61i c Sei f e t7
Responsible Official
(as identified in accordance with 40 CFR 122.22) Jet re y T O 8 r is n U
Street Address: j.I c D PS- Ce o f-yy ( EnTr5 . 4 2_ 16 MSc.,
City Ra Le i�k
State/Zip Code: NIC 2 76 q 9' - 42- 16
Telephone number: (9 Icy 32 4 - 1 2 35
E-mail address: jejl y r e y . o b ria.n.& @ 7-1 Gd p$ . QOV
Section B: Activate New Submitter or Update Existing User
Please complete the Submitter User Details on page 2 for the individuals who will need Submitter
permissions or to update Submitter details, such as adding additional permits,to an existing user.
Submitter permissions can only be assigned by the NCDWR eDMR Administrator. Note: The Owner
and Facility Administrator can deactivate or delete eDMR user permissions for any individual within
its organization, including Submitter permissions.
The Submitter is equivalent to the individual who signs the certification statement on the back of the
Discharge Monitoring Report. The Submitter must be an individual with delegated signatory authority
for the Owner/Organization. If individuals other than the Responsible Official for the Owner have been
delegated signatory authority,the Division of Water Resources must be notified in writing of such
delegations. A delegation of authority form is available from the eDMR website.
In addition to the User Details,please specify the NPDES permit(s)that each user will be associated with
for eDMR submittal. Should additional space be needed for users and/or permits,please make additional
copies of the Submitter User Details page and complete as needed.
NCDWR eDMR Submitter Change Request Form-ver.1.0 Page 1

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Responsible Official Authorization
The Responsible Official,as identified in accordance with 40 CFR 122.22,is the appropriate individual
with the authority to sign reports for the organization.
I, J E F F 1Z E Y T O131: "74.7.-(printed name),have the authority to make this request for
N C-DL-'PT• OF FV-1 B 1 IC 5A FE1 Y (Owner/Organization Name).
I request the NCDWR add or update the eDMR Submitter user permission(s)as indicated above on the
Submitter User Details page.
Di recf'ot;
10 Ce-ntra L CogIneeri (\
ewer es!fn : e Official Signature Title Date
Please return the completed form to the NCDWR eDMR Administrator via:
Fax: or E-mail: or Mail to:
[phone] [e-mail] Information Processing Unit
Attn: eDMR Registration
1617 Mail Service Center
Raleigh,NC 27699-1617
NCDWR eDMR Submitter Change Request Form-ver.1.0 Page 3