Form SFN61205 "Certificate of Representation" - North Dakota

What Is Form SFN61205?

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

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the North Dakota Department of Health;
  • 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 SFN61205 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN61205 "Certificate of Representation" - North Dakota

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CERTIFICATE OF REPRESENTATION
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF AIR QUALITY
SFN 61205 (03-17)
SECTION A - FACILITY INFORMATION*
Facility Name
ND Air Pollution Control Permit Number (If Applicable)
Facility Address (Street & Number)
City
State
ZIP Code
County
*To designate the same representative for more than one facility complete Section E.
SECTION B – RESPONSIBLE OFFICIAL
Name
Title
Company Name
Facility Address (Street & Number)
City
State
ZIP Code
Telephone Number
Fax
Email
SECTION C – DESIGNATED REPRESENTATIVE
Name
Title
Company Name
Facility Address (Street & Number)
City
State
ZIP Code
Telephone Number
Fax
Email
SECTION D – ALTERNATIVE DESIGNATED REPRESENTATIVE
Name
Title
Company Name
Facility Address (Street & Number)
City
State
ZIP Code
Telephone Number
Fax
Email
I certify that I was selected as the designated representative or alternate designated representative (as
applicable) by an agreement binding on the owners and operators of the affected source and each affected
unit at the source.
I certify that I have all necessary authority to carry out my duties and responsibilities under the Clean Air Act
on behalf of the owners and operators of the affected source and each affected unit at the source and that
each such owner and operator shall be fully bound by my representations, actions, inactions, or
submissions.
CERTIFICATE OF REPRESENTATION
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF AIR QUALITY
SFN 61205 (03-17)
SECTION A - FACILITY INFORMATION*
Facility Name
ND Air Pollution Control Permit Number (If Applicable)
Facility Address (Street & Number)
City
State
ZIP Code
County
*To designate the same representative for more than one facility complete Section E.
SECTION B – RESPONSIBLE OFFICIAL
Name
Title
Company Name
Facility Address (Street & Number)
City
State
ZIP Code
Telephone Number
Fax
Email
SECTION C – DESIGNATED REPRESENTATIVE
Name
Title
Company Name
Facility Address (Street & Number)
City
State
ZIP Code
Telephone Number
Fax
Email
SECTION D – ALTERNATIVE DESIGNATED REPRESENTATIVE
Name
Title
Company Name
Facility Address (Street & Number)
City
State
ZIP Code
Telephone Number
Fax
Email
I certify that I was selected as the designated representative or alternate designated representative (as
applicable) by an agreement binding on the owners and operators of the affected source and each affected
unit at the source.
I certify that I have all necessary authority to carry out my duties and responsibilities under the Clean Air Act
on behalf of the owners and operators of the affected source and each affected unit at the source and that
each such owner and operator shall be fully bound by my representations, actions, inactions, or
submissions.
SFN (03-17) Page 2
I certify that the owners and operators of the affected source and each affected unit at the source shall be
bound by any order issued to me by the Administrator, the North Dakota Department of Health, Division of
Air Quality, or a court regarding the source or unit.
Where there are multiple holders of a legal or equitable title to, or a leasehold interest in, an affected unit, or
where a utility or industrial customer purchases power from an affected unit under a life-of-the-unit, firm
power contractual arrangement,
I certify that:
I have given a written notice of my selection as the designated representative or alternate designated
representative (as applicable) and of the agreement by which I was selected to each owner and operator of
the affected source and each affected unit at the source; and
Allowances, and proceeds of transactions involving allowances, will be deemed to be held or distributed in
proportion to each holder's legal, equitable, leasehold, or contractual reservation or entitlement, except that,
if such multiple holders have expressly provided for a different distribution of allowances, allowances and
proceeds of transactions involving allowances will be deemed to be held or distributed in accordance with
the contract.
General
I am authorized to make submission(s) on behalf of the owners and operators of the source or units for
which the submission(s) is made. I certify under penalty of law that I have personally examined, and am
familiar with, the statements and information submitted in this document and all its attachments. Based on
my inquiry of those individuals with primary responsibility for obtaining the information, I certify that the
statements and information are to the best of my knowledge and belief true, accurate, and complete. I am
aware that there are significant penalties for submitting false statements and information or omitting
required statements and information, including the possibility of fine or imprisonment.
Signature of Designated Representative
Date
Signature of Alternate Designated Representative
Date
I authorize the above individual(s) to make submission(s) on behalf of the owners and operators of the
source or units for which the submission(s) is made. I certify under penalty of law that I have personally
authorized the above individuals to submit documents as if I had submitted them. I am aware that there are
significant penalties for submitting false statements and information or omitting required statements and
information, including the possibility of fine or imprisonment and that designating others to submit on my
behalf does not absolve of me responsibly or shield me from civil or criminal penalties.
Signature of Responsible Official
Date
SEND COMPLETED APPLICATION AND ALL ATTACHMENTS TO:
North Dakota Department of Health
Division of Air Quality
918 E Divide Avenue, 2nd Floor
Bismarck, ND 58501-1947
(701)328-5188
SFN (03-17) Page 3
SECTION E – ADDITIONAL FACILITY INFORMATION
Facility Name
ND Air Pollution Control Permit Number (If Applicable)
Facility Address (Street & Number)
City
State
ZIP Code
County
Facility Name
ND Air Pollution Control Permit Number (If Applicable)
Facility Address (Street & Number)
City
State
ZIP Code
County
Facility Name
ND Air Pollution Control Permit Number (If Applicable)
Facility Address (Street & Number)
City
State
ZIP Code
County
Facility Name
ND Air Pollution Control Permit Number (If Applicable)
Facility Address (Street & No.)
City
State
ZIP Code
County
Facility Name
ND Air Pollution Control Permit Number (If Applicable)
Facility Address (Street & Number)
City
State
ZIP Code
County
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