Form CEM-2006 "Legally Responsible Person Autnorization of Approved Signatory" - California

What Is Form CEM-2006?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2013;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CEM-2006 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form CEM-2006 "Legally Responsible Person Autnorization of Approved Signatory" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
LEGALLY RESPONSIBLE PERSON
AUTHORIZATION OF APPROVED SIGNATORY
CEM-2006 (REV 11/2013)
Page of
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
LEGALLY RESPONSIBLE PERSON NAME AND TITLE
LEGALLY RESPONSIBLE PERSON ADDRESS
The Legally Responsible Person appoints the following person:
Authorized approved signatory name and title
Authorized approved signatory address
I hereby agree and further authorize the above-named designated authorized approved signatory to certify all permit registration documents, Numeric Action
Level Exceedance Reports, ATS, Numeric Effluent Limitation Violation Reports, Receiving Water Monitoring Trigger Reports, Annual Reports, and Notices of
Termination in accordance with Section IV.I, Section IV.XVI, Attachment D, and Attachment E of the National Pollutant Discharge Elimination System (NPDES)
General Permit for Storm Water Discharges Associated with Construction and Land Disturbance Activities, Order No. 2010-0014-DWQ & 2012-0006-DWQ,
NPDES No. CAS000002.
I hereby further authorize the above-named designated approved signatory to submit documents electronically to the State Water Resources Control Board
SMARTS database.
Executed this
day of
, 20
at
California
Legally responsible person signature
Approved signatory signature
Legally responsible person name
Approved signatory name
Phone number
Phone number
For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233,
ADA Notice
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
LEGALLY RESPONSIBLE PERSON
AUTHORIZATION OF APPROVED SIGNATORY
CEM-2006 (REV 11/2013)
Page of
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
LEGALLY RESPONSIBLE PERSON NAME AND TITLE
LEGALLY RESPONSIBLE PERSON ADDRESS
The Legally Responsible Person appoints the following person:
Authorized approved signatory name and title
Authorized approved signatory address
I hereby agree and further authorize the above-named designated authorized approved signatory to certify all permit registration documents, Numeric Action
Level Exceedance Reports, ATS, Numeric Effluent Limitation Violation Reports, Receiving Water Monitoring Trigger Reports, Annual Reports, and Notices of
Termination in accordance with Section IV.I, Section IV.XVI, Attachment D, and Attachment E of the National Pollutant Discharge Elimination System (NPDES)
General Permit for Storm Water Discharges Associated with Construction and Land Disturbance Activities, Order No. 2010-0014-DWQ & 2012-0006-DWQ,
NPDES No. CAS000002.
I hereby further authorize the above-named designated approved signatory to submit documents electronically to the State Water Resources Control Board
SMARTS database.
Executed this
day of
, 20
at
California
Legally responsible person signature
Approved signatory signature
Legally responsible person name
Approved signatory name
Phone number
Phone number
For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233,
ADA Notice
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
LEGALLY RESPONSIBLE PERSON
AUTHORIZATION OF APPROVED SIGNATORY
CEM-2006 (REV 11/2013)
Page of
Instructions
General Information
This form is required for compliance with provisions in Section IV.l of the National Pollutant Discharge Elimination System (NPDES) General Permit for
Storm Water Discharges Associated With Construction and Land Disturbance Activities, Order No. 2009-0009-DWQ, amended by 2010-0014-DWQ &
2012-0006-DWQ, NPDES No. CAS000002.
The legally responsible person (LRP) for Caltrans projects is the district director. The LRP may authorize the project resident engineer to be the approved
signatory.
For a local agency, the LRP is either a principal executive officer or ranking elected official. The local agency LRP may authorize the project resident
engineer to be the approved signatory.
For a private entity performing work in the state right-of-way under an encroachment permit, the LRP must be one of the following:
1. For a corporation, a responsible corporate officer.
2. For a partnership or sole proprietorship, a general partner or the proprietor, respectively.
The private entity LRP may not authorize an approved signatory.
Include a copy of the completed form in the project Storm Water Pollution Prevention Plan.
Form
Project Identifier Number
Caltrans projects starting July 1, 2010, will have a project identifier number. For projects without a number, write N/A in the field.
Contract Number/Co/Rte/PM
For local agency encroachment permit projects, write the encroachment permit number in the contract number field.
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