2017-04-10 NPDES Electronic Submission AgreementSubscriber Agreement Page I of 4
Agency: Nebraska Departhnent gf'Enviroimrental Qualio)
Subscriber Agreement Number: 15b8b96I=13=11-44ed-(1123-fcrOccr6l65e01
Generated On: 2017-04-10 1=1:23:13.0
Account Reference: 32906
NetDbIR Subscriber Agreement Instructions Page
This form can be used for permits issued Uy: Nebraska Department of Environnnental Quality, hereafter referrer/ to as "the
Regulatory Authority ".
Purpose
The NetDMR Subscriber Agreement should be used by Clean Water Act National Pollutant Discharge Elimination System (NPDES)
permit holders that would like to apply to submit Discharge Monitoring Reports (DMRs) and other NPDES permit -required reports
electronically, or change/update your reporting status information from a previously -submitted application. Submission of DMRs
electronically is an alternative to using paper forms to fulfill the reporting requirements of the CWA NPDES program pursuant to 40
CFR 122.41(1)(4).
Basic Information on Who Should Fill Out the Subscriber Agreement
• To request use of electronic reporting for DMR information, the Responsible Official, the person who has the authority to sign
permit applications, reports, and other permit -required submittals (e.g... DMRs) as described in 40 CFR § 122.22 (a), can
designate themselves or identify a duly authorized representative to electronically sign the DMRs for the facility.
• If the Responsible Official plans to electronically sign DMRs submitted tlu-ough NetDMR, then the Responsible Official will
also sign as the Signatory Authority named in Section F of the Subscriber Agreement.
• If the Responsible Official plans to authorize someone else to sign and submit the electronic DMRs as described in 40 CFR
§ 122.22(b), the Responsible Official will sign Section E and the duly authorized representative will sign as the Signatory
Authority identified in Section F.
• If a Signatory Authority has more than one NPDES permit for which they are responsible, and the Regulatory Authority allows
multiple permits on a single Subscriber Agreement, then this document allows the Signatory Authority to list multiple permits
on a single Subscriber Agreement as long as the Subscriber is the same person for all the multiple permits listed.
• If the authority to electronically sign for a permit is to be delegated to multiple Signatory Authorities, then each individual
Signatory Authority needs to submit and sign a separate Subscriber Agreement.
• This Subscriber Agreement cannot be used to register multiple permits that are issued by different regulatory authorities.
How to Submit the Subscriber Agreement
Print and sign this form, save a copy for your records, and mail the completed Subscriber Agreement below to your Clean Water Act
Regulatory Authority for their review at the address below.
Nebraska Department of Environmental Quality
Attn: NPDES Permits and Compliance
1200 N Street, Suite 400
Lincoln , NE 68508
You will receive a confirmation email from the Regulatory Authority when your application has been processed and approved. For
assistance or questions please contact Nebraska Department of Environnnental Quality at 402-471-4220 or
NDEQ.NetDMR@nebraska.gov.
A. Signatory Authority Information
The Signatory Authority is the individual that intends to sign DMRs and signs this Subscriber Agreement in Section F.
User Name:
ARSa blairnebraska.org
Subscriber Name:
Al Schoemaker
Organization:
Blair
Email Address:
ARSa blairnebraska.org
Phone Number:
402-426-4191
B. Permit Information
Signing privileges are requested for the following permits:
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Permit ID
Facility Name
Facility Address
Relationship
Authorized By
NE0021482
BLAIR WASTEWATER TREATMENT FACILITY
850 FAIRVIEW DRIVE
Facility
James Realph
BLAIR, NE 68008
This request is (check one):
❑ NEW: a new user request by this facility to use NetDMR reporting
REQUEST FOR REACTIVATION: a User ID re -activation of NetDMR reporting for a facility that had discontinued using
❑ NetDMR
❑ CONTINUATION WITH NEW AUTHORIZATION: an updated Subscriber Agreement submitted because a new Responsible
Official and/or Signatory Authority has been identified at the facility
RENEWAL: an updated form submitted when a permit application is submitted
❑ Permit ID(s):
INACTIVATION: Explain reason for inactivation in the box below and identif}, whether the inactivation is temporary or
❑ permanent
Permit ID(s):
to Permitting Authority (Optional unless Inactivating):
C. Terms and Conditions
• PURPOSE: This agreement creates a legally binding obligation for the signer of the Agreement (the Responsible Official
and/or Signatory Authority) to abide by the terms and conditions for use of the NetDMR System, and memorializes a mutual
understanding that the signer of this agreement is as legally bound, obligated, and responsible by use of the assigned electronic
signature as by a hand-written signature.
• ACCEPTANCE & EFFECT: Acceptance of this agreement by the Regulatory Authority shall be evidenced by notice from the
Regulatory Authority, provided electronically, that this agreement has been approved.
• SUBMITTAL & RECEIPT: A Document shall be deemed to have been submitted when it is accessible to the Regulatory
Authority. A document shall be deemed to have been received when it can be fully processed. No document shall satisfy any
reporting requirement until it is received.
• VERIFICATION: In accordance with the associated certification statement, the signer of the Agreement is responsible for the
truth and accuracy of the content of each submission. The signer of the Agreement also has an affirmative obligation to check
the accuracy of the document as received by the Regulatory Authority and to notify the Regulatory Authority promptly if the
document was sent without authorization or differs in substance in any way from the document that was submitted.
• INABILITY TO TRANSMIT OR FILE REPORTS ELECTRONICALLY: No party shall be liable for any failure to perform
its obligations in connection with any Electronic Transaction or any Electronic Document, where such failure results fi•om any
act or cause beyond such party's control which prevents such party from electronically transmitting or receiving any
Documents, except that the signer of the Agreement (Responsible Official and/or Signatory Authority) is nonetheless required
to submit records or information required by law via other means, as provided by applicable law and within the time period
provided by such law.
• SEVERABILITY: Any provision of the Agreement which is determined to be invalid or unenforceable will be ineffective to
the extent of such determination without invalidating the remaining provisions of this Agreement or affecting the validity or
enforceability of such remaining provisions.
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TERMINATION AND RENEWAL: The Agreement may be terminated at any time by the Regulatory Authority. Upon
termination of this agreement, the associated ability to submit electronic information through the NetDMR system will be
terminated. The Regulatory Authority will provide notification of termination, including the date on which termination takes
effect. A new Responsible Official and/or Signatory Authority must resubmit this form at the time that a new permit
application is submitted or when Responsible Official and/or Signatory Authority responsibility transfers from one person to
another.
-Note: Termination of this agreement may, eliminate the ability to comply with permit requirements for any continuing
operations. Paper DMR Reports will only be accepted under this permit where the permittee has provided sufficient
,justification and obtained prior approval from the Regulatory Authority.
• GOVERNING LAW: This Agreement shall be governed by and interpreted in accordance with 40 CFR §122 and 40 CFR §3.
AGREEMENT:
1. I agree to protect the electronic signature device, consisting of my NetDMR system user name and password, from use
by anyone except Inc. Specifically, I agree to maintain the secrecy of my password and security- and challenge -
question answers; I will not divulge or delegate my user name and password to any other individual; I will not write or
save my password or challenge question/answer pairs to a script or other mechanism that allows its use or application
by someone other than me;
2. I agree to contact the Regulatory Authority Nebraska Department of Environmental Quality at 402-471-4220 or
NDEQ.NetDMR @ nebraska.gov within 24 hours if any of the following occurs:
■ suspicion or determination that my user name, password, security question answer, or challenge question
answers may have been lost, stolen or otherwise compromised;
■ receipt of an e-mail notification for any activity that I do not believe that I performed;
■ if, after receipt of COR, there is any evidence of discrepancy between any electronic document 1 have signed
.and submitted and what the NetDMR system has received from me;
■ if I do not receive an e-mail notification within 24 hours for any submission electronically signed using my
credentials; or
• if I cease to represent the regulated entity specified above as signatory of that organization's electronic
submissions.
3. 1 understand and agree that 1 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;
4. I understand that I will be informed through my registered electronic mail (e-mail) address whenever my user name,
password, or challenge question/answer pairs have been modified;
5. I agree to provide and maintain an email address by which to receive communications from the NetDMR system. I
understand that this account must be accessible only by me and that I have an affirmative obligation to check this email
account regularly. If any email sent to me by the NetDMR system is returned as undeliverable, I will explain why this
occurred when requested by the Nebraska Department of Environmental Quality;
6. 1 understand that the NetDMR system reports the last date my user name and password were used immediately after
successfully logging in to the system;
7. 1 understand that whenever I electronically sign and submit an electronic document to the NetDMR system, I will
receive an e-mail at my registered e-mail address; This e-mail will inform me that a submission has been made to the
system from my user account and will contain instructions to view information regarding the submission, including the
Copy of Record (COR) for the submission; and
8. I 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 company's electronic submissions.
D. Inactivation/Removal
Permittee must indicate reason for inactivation in Section B of the form. This is done to inform the Regulatory Authority whether the
permittee is no longer in business or has a temporary reason for inactivation.
E. Responsible Official Authorization
The Responsible Official is the appropriate individual identified under 40 CFR § 122.22(a) with the authority to sign permit
applications, reports, and other permit -required submittals (e.g., DMRs). The Responsible Official can also delegate the authority to
electronically sign DMRs to a duly authorized representative(s) as described in 40 CFR §122.22(b).
Permit ID(s): NE0021482
1, James Realph Mayor, have the authority to enter into this Agreement for BLAIR WASTEWATER TREATMENT FACILITY and
Permit ID NE0021482 under the applicable standards. I request Nebraska Department of Environmental Quality grant At Schoemaker
the ability to submit DMRs for Permit ID NE0021482.
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c
James Realph
Mayoi
Responsible Official Signatut - Title Date
F. Signatory Authority Signature
The Signatory Authority is the NetDMR user that submits this agreement to request approval to electronically sign DMRs. The
Signatory Authority has the authority to sign DMRs under 40 CPR § 122.22(a) or is a duly authorized representative(s) who has been
delegated the authority to electronically sign DMRs by the Responsible Official as described in 40 CFR § 122.22(b).
Permit ID: NE0021482
I, Al Schoemaker, am authorized by the signatory authority named in Part E of this document, who does have the authority under the
applicable standards, to enter into this agreement for BLAIR WASTEWATER TREATMENT FACILITY and Permit ID NE0021482.
By submitting this application for NE0021482, I, Al Schoemaker, have read, understand, and accept the terms and conditions of this
subscriber 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.
Signatory Authority Signature Title
Print this form, save a copy for your records, and mail to:
Nebraska Department of Environmental Quality
Attn: NPDES Permits and Compliance
1200 N Street, Suite 400
Lincoln, NE 68508
Checklist - Regulatory Authority Use Only:
Check
Information
Name
Date
Form Received by
Verified ICIS-NPDES Permit Limits
Regulatory Authority Approves NetDMR Authorization
ICIS-NPDES NetDMR Flag Populated
User Approved in NetDMR Application
Notification to User
Inactivated?
Date
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