"Duly Authorized Representative (Dar) Delegation Form (Water)" - Mississippi

Duly Authorized Representative (Dar) Delegation Form (Water) is a legal document that was released by the Mississippi Department of Environmental Quality - a government authority operating within Mississippi.

Form Details:

  • The latest edition currently provided by the Mississippi 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 fillable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Department of Environmental Quality.

ADVERTISEMENT
ADVERTISEMENT

Download "Duly Authorized Representative (Dar) Delegation Form (Water)" - Mississippi

Download PDF

Fill PDF online

Rate (4.4 / 5) 18 votes
Page background image
 
Duly Authorized Representative (DAR) Delegation Form (Water)
 
Facility Name:
AI#:
Prior to completing this form, please ensure the person completing this form is an authorized signatory. An authorized signatory is as
follows:
(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, a general partner or the proprietor, respectively; or
(3) For a municipality, State, Federal, or other public agency, 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.
This authorization may specify either named individual(s) or position(s) that must have responsibility for the overall operation of the
regulated facility, activity, or environmental matters for the company. Please identify either named individual(s) or position(s) (not
both) and then complete the “Facility Contact Identification Form” for identified individuals.
I certify I am an Authorized Signatory and am requesting the following persons/positions to be Duly Authorized Representative
(DAR) in order to complete reports required by MDEQ permits and submit information requested by the MDEQ Director on behalf of
the above facility.
_________________________________________
______________________________________________
_________________________________________
______________________________________________
_________________________________________
______________________________________________
_________________________________________
______________________________________________
 
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.
 
_____________________________________
                                                                                                                     
Typed or printed name of authorized signatory
Signature of authorized signatory
_____________________________________
                                                                                                                     
Title of authorized signatory
Date
 
Duly Authorized Representative (DAR) Delegation Form (Water)
 
Facility Name:
AI#:
Prior to completing this form, please ensure the person completing this form is an authorized signatory. An authorized signatory is as
follows:
(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, a general partner or the proprietor, respectively; or
(3) For a municipality, State, Federal, or other public agency, 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.
This authorization may specify either named individual(s) or position(s) that must have responsibility for the overall operation of the
regulated facility, activity, or environmental matters for the company. Please identify either named individual(s) or position(s) (not
both) and then complete the “Facility Contact Identification Form” for identified individuals.
I certify I am an Authorized Signatory and am requesting the following persons/positions to be Duly Authorized Representative
(DAR) in order to complete reports required by MDEQ permits and submit information requested by the MDEQ Director on behalf of
the above facility.
_________________________________________
______________________________________________
_________________________________________
______________________________________________
_________________________________________
______________________________________________
_________________________________________
______________________________________________
 
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.
 
_____________________________________
                                                                                                                     
Typed or printed name of authorized signatory
Signature of authorized signatory
_____________________________________
                                                                                                                     
Title of authorized signatory
Date
Facility Contact Identification Form
 
Facility Name:
Facility Number:
If an existing contact is being replaced with a new contact, please identify the existing contact that is to be replaced on the
 
“Existing Contact” line.
 
New Facility Contact:
Title:
Existing Facility Contact to be replaced (if applicable): ______________________________________
Facility Contact Mailing Address:
 
 
 
Facility Contact Telephone No:
Facility Email:
 
 
 
New Facility Contact:
Title:
Existing Facility Contact to be replaced (if applicable): ______________________________________
Facility Contact Mailing Address:
 
 
 
Facility Contact Telephone No:
Facility Email:
 
 
 
New Facility Contact:
Title:
Existing Facility Contact to be replaced (if applicable): ______________________________________
Facility Contact Mailing Address:
 
 
 
Facility Contact Telephone No:
Facility Email:
 
 
New Facility Contact:
Title: ____________________________
Existing Facility Contact to be replaced (if applicable): ___________________________________
Facility Contact Mailing Address:
 
 
 
Facility Contact Telephone No:
Facility Email:
 
Page of 2