Department of Ecology 4/29/2025 - Laserfiche WebLink

Electronic Signature Agreement Form _t .: : Iowa DEPARTMENT OF ECOLOGY State of Washington Washington State Department of Ecology Water Quality Program Web site: https://ecology.wa.gov/wgwebportal/ is Site Location Information 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 that have the same Permittee (Responsible Official) otherwise complete separate Form for each request. Permit Number/Application ID: WAG643009 Permit Name: Permit Address: City/State/Zip: Everett- Lake Chaplain 6133 Lake Chaplain Rd Monroe, WA 98272 2. Electronic Signer Contact Information Select One Role: rav ■ Facility Signer Signature Account User Name: Jeff Mitchell Full Name: Jeffrey Justin Mitchell Work Mailing Address: 6133 Lake Chaplain Road City/State/Zip: Monroe, WA 98272 Work Phone No. (Ext): 425 257 8201 Work Email Address: lmitchell@everettwa.gov Facility Coordinator 3. Proof of Identity 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). 4. Electronic Signature Agreement and Certification Statement 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. 10/2024 ECY070-743 Page 1of4