01_18382348_Specs_Attachment 10 Delegation Signatory.pdf

January 2022

Alaska Department of Environmental Conservation Division of Water, Compliance and Enforcement Program

555 Cordova Street, Anchorage, AK 99501 Toll Free: 1-877-569-4114 Anchorage/International: 907-269-4114 Fax: 907-269-4604 Email: DEC-wqreporting@alaska.gov

DELEGATION OF SIGNATORY AUTHORITY

for Alaska Pollutant Discharge Elimination System (APDES) Permit Applications and Reports

Permit tracking number(s): _____________________________________________________________________________________

Select the delegation below (A) or (B) that applies and enter name(s) of duly authorized representative(s):

☐ Delegated Authority – 18 AAC 83.385(b)(2)(A) In accordance with 18 AAC 83.385, I certify that the following individual(s) or a position has responsibility for the overall operation of the regulated facility or activity, including the position of plant manager, operator of a well or a well field, superintendent, or position of equivalent responsibility and authorize him/her to act as signatory official for purposes of signing APDES permits and reports.

Or ☐ Delegation Authority – 18 AAC 83.385(b)(2)(B) In accordance with 18 AAC 83.385, I certify that the following individual or position has overall responsibility for environmental matters for the company and authorize him/her to act as signatory official for purposes of signing APDES permits and reports.

Duly Authorized Representative(s):

Name Organization Title

Phone Email Mailing Address (Street/PO Box, City, State, Zip)

Name Organization Title

Phone Email Mailing Address (Street/PO Box, City, State, Zip)

Name Organization Title

Phone Email Mailing Address (Street/PO Box, City, State, Zip)

Note: If an authorization is no longer effective because a different individual or position has responsibility for the overall operation of the facility, a new authorization satisfying the requirements 18 AAC 83.385(b) must be submitted to the department before or together with any report, information, or application to be signed by authorized representative.

Delegator/Certifying Official:

An Alaska Pollutant Discharge Elimination System (APDES) permit application or report must be signed by an individual with the appropriate authority per 18 AAC 83.385.

For additional information, please refer to 18 AAC 83.385 which can be accessed at: https://www.akleg.gov/basis/aac.asp#18.83.385.

Corporate Executive Officer 18 AAC 83.385(a)(1)(A)

For a corporation, a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy- or decision-making functions for the corporation;

Corporate Operations Manager 18 AAC 83.385(a)(1(B)

For a corporation, the manager of one or more manufacturing, production, or operating facilities, if

(i) the manager is authorized to make management decisions that govern the operation of the regulated facility, including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long term environmental compliance with environmental statutes and regulations;

(ii) the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and

(iii) authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures.

Sole Proprietor or General Partner

18 AAC 83.385(a)(2) For a partnership or sole proprietorship, the general partner or the proprietor respectively.

Public Agency, Chief Executive Officer 18 AAC 83.385 (a)(3)(A)

For a municipality, state, or other public agency, the chief executive officer of the agency.

Public Agency, Senior Executive Officer 18 AAC 83.385 (a)(3)(B)

For a municipality, state, or other public agency, a senior executive officer having responsibility for the overall operations of a principal geographic unit or division of the agency.

I 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. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

Name Organization Title

Phone Email Mailing Address (Street/PO Box, City, State, Zip)

Signature/Delegator-Certifying Official Date mailto:DEC-wqreporting@alaska.gov https://www.akleg.gov/basis/aac.asp#18.83.385