"Npdes Duly Authorized Representative Form" - Oregon

Npdes Duly Authorized Representative Form is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

Form Details:

  • Released on March 27, 2017;
  • The latest edition currently provided by the Oregon Department of Environmental Quality;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Oregon Department of Environmental Quality.

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Download "Npdes Duly Authorized Representative Form" - Oregon

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Oregon Department of Environmental Quality
NPDES Duly Authorized Representative Form
Permittee Legal Name:
DEQ Facility/File ID:
Facility Common Name:
DEQ Permit #
I hereby certify that I am qualified under 40 §CFR 122.22(a) to be the signatory for NPDES permit applications and I am appointing
the following individuals or named positions to act as Duly Authorized Representatives in accordance with 40 CFR § 122.22(b) for
signatures on reports required by NPDES permits and other information requested by DEQ. These individuals or positions are
responsible for the overall operation of the regulated facility or activity, or have overall responsibility for environmental matters for
the company as required by 40 CFR § 122.22(b).
Name w/Position Title or Position Title
Telephone
Email
I understand that if this authorization is no longer accurate because a different individual or position has responsibility for the overall
operation of the facility, I must submit a new authorization form to DEQ prior to or together with any reports or information signed
by the new Duly Authorized Representative.
Signature*:
______________________________________________________
Print Name: ______________________________________________________
Date: _____________________________
Title: ____________________________________________________________
Submit completed form to the appropriate DEQ regional office:
Water Quality Permit Coordinator
Water Quality Permit Coordinator
Water Quality Permit Coordinator
DEQ Western Region
DEQ Eastern Region
DEQ Northwest Region
4026 Faiview Industrial Drive SE
800 SE Emigrant, #330
700 Multnomah Street, Suite 600
2
Salem, OR 9730
Pendleton, OR 97801
Portland, OR 97232
1)
For a corporation: By a responsible corporate officer. For the purpose of this section, a responsible corporate officer means: (i) 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, or (ii) the manager of one or more manufacturing,
production, or operating facilities, provided, the manager is authorized to make management decisions which 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 laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather
complete and accurate information for permit application requirements; and where authority to sign documents has been assigned
or delegated to the manager in accordance with corporate procedures.
2)
For a partnership or sole proprietorship: By a general partner or the proprietor, respectively.
3)
For a municipality, State, Federal, or other public agency: By either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a Federal agency includes: (i) The chief executive officer of the
agency, or (ii) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the
agency.
4) For a limited liability company: A member.
5) For a trust: Acting trustee.
20170327~TLB
Oregon Department of Environmental Quality
NPDES Duly Authorized Representative Form
Permittee Legal Name:
DEQ Facility/File ID:
Facility Common Name:
DEQ Permit #
I hereby certify that I am qualified under 40 §CFR 122.22(a) to be the signatory for NPDES permit applications and I am appointing
the following individuals or named positions to act as Duly Authorized Representatives in accordance with 40 CFR § 122.22(b) for
signatures on reports required by NPDES permits and other information requested by DEQ. These individuals or positions are
responsible for the overall operation of the regulated facility or activity, or have overall responsibility for environmental matters for
the company as required by 40 CFR § 122.22(b).
Name w/Position Title or Position Title
Telephone
Email
I understand that if this authorization is no longer accurate because a different individual or position has responsibility for the overall
operation of the facility, I must submit a new authorization form to DEQ prior to or together with any reports or information signed
by the new Duly Authorized Representative.
Signature*:
______________________________________________________
Print Name: ______________________________________________________
Date: _____________________________
Title: ____________________________________________________________
Submit completed form to the appropriate DEQ regional office:
Water Quality Permit Coordinator
Water Quality Permit Coordinator
Water Quality Permit Coordinator
DEQ Western Region
DEQ Eastern Region
DEQ Northwest Region
4026 Faiview Industrial Drive SE
800 SE Emigrant, #330
700 Multnomah Street, Suite 600
2
Salem, OR 9730
Pendleton, OR 97801
Portland, OR 97232
1)
For a corporation: By a responsible corporate officer. For the purpose of this section, a responsible corporate officer means: (i) 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, or (ii) the manager of one or more manufacturing,
production, or operating facilities, provided, the manager is authorized to make management decisions which 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 laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather
complete and accurate information for permit application requirements; and where authority to sign documents has been assigned
or delegated to the manager in accordance with corporate procedures.
2)
For a partnership or sole proprietorship: By a general partner or the proprietor, respectively.
3)
For a municipality, State, Federal, or other public agency: By either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a Federal agency includes: (i) The chief executive officer of the
agency, or (ii) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the
agency.
4) For a limited liability company: A member.
5) For a trust: Acting trustee.
20170327~TLB