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WA ST Dept of Ecology 12/6/2023
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WA ST Dept of Ecology 12/6/2023
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Last modified
12/8/2023 3:03:37 PM
Creation date
12/8/2023 3:03:28 PM
Metadata
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Template:
Contracts
Contractor's Name
WA ST Dept of Ecology
Approval Date
12/6/2023
Department
Public Works
Department Project Manager
Tom Norris
Subject / Project Title
Electronic Signature Agreement Form - Water Quality Program Permit No. WAG643009
Tracking Number
0004061
Total Compensation
$0.00
Contract Type
Agreement
Contract Subtype
Other Agreements
Retention Period
6 Years Then Destroy
Imported from EPIC
No
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5i3 . _..` <br /> tilp <br /> I agree that I will: I agree that I will not <br /> • Protect my Electronic Signature account,which includes • Let anyone else use my Electronic Signature account. <br /> my answers to the verification questions and my <br /> password; <br /> • Review the content and meaning of my submitted Annual <br /> Reports and Notifications; <br /> • Within 24 hours of discovery, report to Ecology if: <br /> o My Electronic Signature account is lost,stolen or used <br /> by someone else; <br /> o There is any difference between the information I <br /> submitted and the information displayed in WebDMR; <br /> o My role as asiigner for this organization changes. <br /> Agree: / 4v (initial here) Agree: (initial here) <br /> i/G fbu2- -/t254,4 t- (print Electronic Signer's name), understand that: <br /> 1. My electronic signature is legally the same as my handwritten signature for the purpose of compliance with the relevant <br /> environmental regulations; <br /> 2. A failure to timely notify Ecology of a possible misuse of my Electronic Signature account may result in my liability for the <br /> information submitted; <br /> 3. There are significant penalties for submitting false information, including possible fines and imprisonment, related to the <br /> federal Department of Justice and federal environmental program; <br /> 4. I will be asked to verify that I am following the rules outlined in this agreement when I electronically submit documents. <br /> tgrjaffs of `n a ig R r ' This form cannot be processed without a handwritten signature. <br /> .A116444A44 1Z ` 11/30/2 023 --- <br /> Electronic Signer's Signature Date <br /> Thomas Norris Water Plant Manager <br /> Name(print or type) Title <br /> • j t tQifvb d))g ` ; This form cannot be processed without a handwritten signature. <br /> I, Cassie Franklin (insert name of permittee or responsible official)acknowledge that the individual named <br /> above works at/for City of Everett Water Filtration Plant (insert site/facility name)and is authorized to submit <br /> documents on the site's/facility's behalf. I understand that I will be contacted by Ecology to validate the account holder's <br /> employment at the site/facility name listed above. <br /> - a Jilt" )'2O1 <br /> S natur Date <br /> Cassie Franklin Mayor <br /> Name(print or type) Title <br /> Note:You may skip this section if the responsible official has written,signed,and attached a delegation letter to this form or if the responsible <br /> official completes this form. <br /> To request an ADA accommodation, contact Ecology by phone at 360-407-6401 or email at <br /> ecyadacoordinator@ecy.wa.gov, or visit https://ecology.wa.gov/accessibility.For Relay Service or TTY call 711 or <br /> 877-833-6341. <br /> 10/2023 qTT <br /> C rk <br />
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