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Electronic Signature Agreement Form ESAF <br /> - Washington State Department of Ecology Water Quality Program <br /> DEPARTMENT OF Web site: <br /> ECOLOGY https://ecology.wa.gov/wowebportal/ <br /> State at Washington <br /> If you are applying for multiple facilities/permits, please include a list containing the site location information <br /> and permit numbers for all requested facilities/permits that have the same Permittee (Responsible Official) <br /> otherwise complete separate Form for each request. <br /> Permit Number/Application ID: WA0024490 <br /> Permit Name: City of Everett-Water Pollution Control Facility <br /> Permit Address: 4027 4th St SE <br /> City/State/Zip: Everett, WA 98201 <br /> G + u <br /> 6 Vs@ C` E4F � £ .. sx. .. <br /> Select One Role: [] Facility Signer 6— I Facility Coordinator <br /> • <br /> Signature Account User Name: cmerwede <br /> Full Name: Chris Merwede <br /> Work Mailing Address: 3200 Cedar St. <br /> City/State/Zip: Everett, WA 98201 <br /> Work Phone No. (Ext): 425.257.7865 <br /> Work Email Address: cmerwede@everettwa.gov <br /> 3.Proof of Identity <br /> Please include a copy of one of the following documents, with your name on the document,with <br /> your ESAF to prove your association with the facility-(ies): <br /> • Your permit's letter of coverage; <br /> • Your permit's cover sheet; <br /> • A previously submitted DMR; <br /> • A correspondence from Ecology that has both the facility name and permit number on the same page; <br /> • Signature authority delegation letter signed by the permittee (responsible official). <br /> 4.Electronic Signature Agreement and Certification Statement <br /> By completing and submitting this form to Ecology, I agree to follow the rules and procedures governing the <br /> Electronic Signature account. I also agree that the reports and documents I submit under my Electronic <br /> Signature will be used as the corresponding paper report would. <br /> 10/2024 ECY070-743 Page 1 of 4 <br />