WA ST Dept of Ecology 12/6/2023 - Laserfiche WebLink

Electronic Signature Agreement Form ESAF Washington State Department of Ecology For Ecology Use Only Date Received: Water Quality Program Form Reviewed Entered Verified DEPA0.TMENT nr Headquarters:(360)407-7097 COt.OGY Web site:httes:ilecotogv.wa,gov/wowebportaU ESAF Stan oe wa,t�n$ta, 1. Site Location Information ,rii e a tt� t ��e If you are applying for multiple facilities/permits,please include a list containing the site location information and permit numbers for all requested facilities/permits. Permit Name: Water Treatment Plant General permit Permit Address: 6133 Lake Chaplain Rd. CitylState/Zip: Monroe,Washington 98272 Permit Number: WAG643009 2.Electronic Signer Contact Information , ° aw � 41..4,. lk , ,R„ o ,1 Role: 0 Facility Signer 0 Facility Coordinator Signature Account User Name; tnorris2023 Full Name: Thomas Norris Work Mailing Address: 3200 Cedar Street City/State/Zip: Everett,Washington 98201-4516 Work Phone No.(Ext): (425)257-8201 Work Email Address: Tnorris@everettwa.gov 3. Proof of Identity }1,44 ,, 14 Please include a copy of one of the following documents,with your name on the document,with your ESAF to prove your association with the facility-(ies): • Your permit's letter of coverage; • Your permit's cover sheet; • A previously submitted DMR; • A correspondence from Ecology that has both the facility name and permit number on the same page; • Signature authority delegation letter signed by the permittee(responsible official). lire hl 4. Electronic Signature Agreement and Certification Statement M By completing and submitting this form to Ecology,i agree to follow the rules and procedures governing the Electronic Signature account. I also agree that the reports and documents I submit under my Electronic Signature will be used as the corresponding paper report would. 5.Clean Water Act Certification Statement All submittals to the Department of Ecology under this WQWebPortal application are subject to the following certification,as required by federal and state regulations: l 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. The information submitted is, to the best of my knowledge and belief, true,accurate, and complete and I am aware that there are significant penalties for submitting false information,including the possibility of fine and imprisonment for knowing violations. 10/2023