WA ST Dept of Ecology 2/15/2022 - Laserfiche WebLink

2/11/22, 12:43 PM WQWebNOI-Print Certification Application Id: 38296 Certification Received: (Ecology use) Facility/Site Name: Everett Water Pollution Control Facility Permit Number: (Ecology use) Facility Address: 4027 4TH ST SE Facility County: Snohomish EVERETT, WA 98205 Permittee Name: Permittee Title: Permittee Email: Permittee Phone: Permittee Address: Company Name: Certification of Permittee "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system or those directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations," / ' tkrOft— Printed Na •- Comp. y Title Vi 5 72-? Signature of Permitt-- Date * Federal regulations require this application is signed by one of the following: A. For a corporation: By a responsible corporate officer, of at least the level of vice president. B. For a partnership or sole proprietorship: By a general partner or the proprietor, respectively. C. For a municipality, state, federal, or other public facility: By either a principal executive officer or ranking elected official. Please print, sign and mail this form to the following address: ATTN: Water Quality Program - Puget Sound Nutrient Permit Administrator Washington State Department of Ecology PO Box 330316 Shoreline, WA 98133-9716 https://secureaccess.wa.gov/ecy/wgwebportal/wgwebnoi/PrintPaperCertification.aspx?id=38296 1/1