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7. Signature <br />This form cannot be processed without a <br />handwritten signature. <br />Ojet-t),(1 <br />Signer's Handwritten Signature <br />tli It - <br />Name (print ) <br />H <br />Date <br />Eloteng (AiocC Csir I lin% /70 v•) c <br />Title ffri6 Pke <br />8. Signature of Permittee (Responsible Official) <br />This form cannot be processed without a <br />handwritten signature. <br />I, (insert name of permittee or responsible official) acknowledge <br />that the individual named above works at/for (insert site/facility name) <br />and is authorized to submit documents on the site's/facility's behalf. I understand that I may be <br />contacted by Ecology to validate the account holder's employment at the site/facility name listed <br />above. <br />Handwritten Signature Date <br />ac6t.¢ ftank-kun <br />Name (print) Title <br />Mcuoy <br />Note: You may skip this section if the responsible official has written, signed, and attached a delegation <br />letter to this form or if the responsible 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. <br />For Relay Service or TTY call 711 or 877-833-6341 <br />*To expedite access, we are accepting scanned Electronic Signature Agreement Forms (ESAF). You <br />are required to mail the original signed ESAF to Ecology for our official records. <br />AT <br />XIT=Sl.1 <br />Deputy ity erk <br />10/2024 ECY070-743 <br />Page 3of4 <br />