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Home My WebLink AboutWashington State, Department of Ecology, Water Quality Program - 110617t (�� , Electronic Signature Agreement Form Washington State Department of Ecology Water Quality Program For Ecology Use Only Date Received: Form Reviewed Entered Verified DEPARTMENT nF Headquarters: (360) 407-6600 ECOLOGY Web site: www.ecy.wa.gov/programs/wq o S'alr f Washer,�,tnir ESAF 1. 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. Site/Facility Name: Jefferson County Quilcene Pit/ Jefferson County Penny Creek Pit Site Location Address: 295312 Hwy 101 / Penny Creek Rd City/State/Zip: Quilcene WA 98376 / Quilcene WA 98376 Permit Number: WAG501130 /WAG501133 2. Electronic Signer Contact Information Role: ❑■ Facility Signer ❑ Facility Coordinator Signature Account User Name: louj@co.jefferson.wa.us Full Name: Louis Johnson Work Mailing Address: PO Box 1200 City/State/Zip: Port Hadlock WA 98339 Work Phone No. (Ext): 360-385-0890 Work Email Address: louj@co.jefferson.wa.us 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.uENiatronlc Signa m9 andn ent xr y , r 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. I want to submit the following report(s) or document(s) using WQWebPortal with an electronic signature. ❑ Discharge Monitoring Reports ❑ Notice of Intent (Permit Applications) ❑ Certificate of No Exposure 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: / 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 / am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. 6. Certification Statement I agree that I will: I agree that I will not • Protect my Electronic Signature account, which includes • Let anyone else use my Electronic Signature account. my answers to the verification questions and my password; • Review the content and meaning of my submitted Annual Reports and Notifications; • Within 24 hours of discovery, report to Ecology if: o My Electronic Signature account is lost, stolen or used by someone else; o There is any difference between the information I submitted and the information displayed in WebDMR; o My role as a signer for this organization changes. IWC IWJ Agree: (initial here) Agree: (initial here) Kathleen Kier Louis Johnson (insert name of permittee or responsible official) acknowledge that (person being assigned) is authorized to be an administrator on the site's/facility's behalf. I understand that I will be contacted by Ecology to validate the account holder's employment at the site/facility name listed above. Signature Kathleen Kler Name (print or type) it c- 20/7 Date Chair, Board of Commissioners Title Note: You may skip this section if the responsible official has written, signed, and attached a delegation letter to this form, if the responsible official completes this form, or if the responsible official is not assigning a person to the administrator role. Mail the signed electronic signature agreement and additional document(s) to one of the following Ecology office. For permit numbers starting with WARS, please mail to one of the following Department of Ecology Units: Major Industrial Unit Washington Department of Ecology Water Quality Program Major Industrial Unit P.O. Box 47600 Olympia, WA 98504-7600 360-407-6945 Stormwater Permit Facilities - Industrial and Construction Stormwater Washington Department of Ecology Water Quality Program Stormwater Unit P.O. Box 47696 Olympia, WA 98504-7696 360-407-6600 For all other permits, please contact one of the follow offices. Clallam, Clark, Cowlitz, Grays Harbor, Jefferson, Mason, Adams, Asotin, Columbia, Ferry, Franklin, Garfield, Grant, Lewis, Pacific, Pierce, Skamania, Thurston, and Lincoln, Pend Oreille, Spokane, Stevens, Walla Walla, and Wahkiakum counties Whitman counties Washington Department of Ecology Water Quality Program - SWRO PO Box 47775 Olympia, WA 98504-7775 360407-6300 Benton, Chelan, Douglas, Kittitas, Klickitat, Okanogan, and Yakima counties Washington Department of Ecology Water Quality Program - CRO 15 West Yakima Ave -- Suite 200 Yakima, WA 98902-3452 509-575-2490 Washington Department of Ecology Water Quality Program - ERO N. 4601 Monroe Spokane, WA 99205-1295 509-329-3400 Island, King, Kitsap, San Juan, Skagit, Snohomish, and Whatcom counties Washington Department of Ecology Water Quality Program - NWRO ATTN: Chris Smith 3190 - 160th Ave. SE Bellevue, WA 98008-5452 425-649-7000 Department of Central Services O Consent Agenda Page 1 of 1 Jefferson County Board of Commissioners Agenda Request To: Board of Commissioners Philip Morley, County Administrator N From: Mark McCauley, Central Services' iD rector Agenda Date: November 6, 2017 Subject: Dept. of Ecology Electronic Signature Agreement Statement of Issue: The State of Washington Department of Ecology recently began requiring electronic submittal of basic monitoring reports related to the operation of the County's gravel pits. This electronic submittal requires an electronic signature and Ecology requires each county to delegate authority for those electronic signatures by action of its Board of Commissioners. Analysis/Strategic Goals/Pros Ft Cons: This action is required by Ecology to continue operating the Quilcene Pit under Ecology's Sand and Gravel General Permit. Fiscal Impact/Cost Benefit Analysis: No impact beyond the processing time required to complete this form. Recommendation: Complete the Signature of Permittee (Responsible Official) in Section 8 and the Assign Administrator in Section 9 and return the attached form to Fleet Services for processing. Department Contact: Lou Johnson, Manager of Fleet Services, 385-0890 Rev' By: Philip Morley, lou ty Administrat r Date