AG 15-060 - WA STATE DEPARTMENT OF ECOLOGY RETURN TO: oh
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
1. ORIGINATING DEPT/DIV: PUBLIC WORKS/ SW M
2. ORIGINATING STAFF PERSON: 14 ILAAAM APPI oN ExT: 2-7 I I 3. DATE REQ.BY:
4. TYPE OF DOCUMENT(CHECK ONE):
❑ CONTRACTOR SELECTION DOCUMENT(E.G.,RFB,RFP,RFQ)
❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT
❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT
❑ GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES/CDBG
❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT(E.G.BOND RELATED DOCUMENTS)
❑ ORDINANCE ❑ RESOLUTION
❑ CONTRACT AMENDMENT(AG#): ❑ INTERLOCAL
verOTHER ELE7n0/WL S/6A/ATWE�� �S�ETO F02. 5rATE OF WASH/A*TML.
5. PROJECT NAME: /Or 7
6. NAME OF CONTRACTOR: e
ADDRESS: TELEPHONE:
E-MAIL: FAX:
SIGNATURE NAME: TITLE:
7. EXHIBITS AND ATTACHMENTS:❑ SCOPE,WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS/CERTIFICATE ❑ ALL
OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS
CFW LICENSE# BL,EXP. 12/31/ UBI# ,EXP. / /
8. TERM: COMMENCEMENT DATE: ei4 `lity14 L COMPLETION DATE:
9. TOTAL COMPENSATION:$ �� U (INCLUDE EXPENSES AND SALES TAX,IF ANY)
(IF CALCULATED ON HOURLY ABOR CHARGE-ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE: ❑YES ❑NO IF YES,MAXIMUM DOLLAR AMOUNT: $
IS SALES TAX OWED: ❑YES ❑NO IF YES,$ PAID BY: ❑CONTRACTOR ❑CITY
❑ PURCHASING: PLEASE CHARGE TO: JU/P
10. DOCUMENT/CONTRACT REVIEW INITIAL/DATE REVIEWED INITIAL/DATE APPROVED
❑ PROJECT MANAGER
❑ DIVISION MANAGER
u-DEPUTY DIRECTOR 1.- 3JSf/C
3/1 DIRECTOR
❑ RISK MANAGEMENT (IF APPLICABLE)
sSLAW DEPT :AM°
11. COUNCIL APPROVAL(IF APPLICABLE) COMMITTEE APPROVAL DATE: COUNCIL APPROVAL DATE:
12. CONTRACT SIGNATURE ROUTING
❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D:
❑ ATTACH: SIGNATURE AUTHORITY,INSURANCE CERTIFICATE,LICENSES,EXHIBITS
INITIAL/DATE SIG/ D
❑ LAW DEPT it
CHI F OF STAFF 4.1 A.iA..I
G✓SIGNATORY(MAYOR OR DIRECTOR) ..miff/ S
❑ CITY CLERK
❑ ASSIGNED AG# AG# IS-OU�� _
❑ SIGNED COPY RETURNED DATE SENT: Obit li(7 )h
❑RETURN ONE ORIGINAL
COMMENTS: t
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11/9
Electronic Signature Agreement Form ESAF
41
Washington State Department of Ecology For Ecology Use Only Date Received:
Water Quality Program
Form Reviewed Entered Verified
DEPARTMENT OF Headquarters:(360)407-7097
ECOLOGY Web site:www.ecy.wa.cloy/programs/m:1
ESAF
1. Site Location information
If you are applying for multiple facilities/permits, please include a list containing the site location information and permit numbers for
all requested facilities/permits.
Site/Facility Name: £it+1y C{- I"- C,‘eYa.l.WWI
Site Location Address: 3 2,C c P Vt'n (k r. �01,4-i`1
City/State/Zip: (----e d€X&ti to y IN A 61'i'06�S
Permit Number: t A R(UccJ(e
2.Electronic Signer Contact Information =:
Role: Facility Signer ❑ Facility Coordinator
Signature Account User Name: rea W Cik May(
Full Name: '3"-t PM Fcir Ve.-I.i
Work Mailing Address: 3-2,3 Z S 8+' P U e v.% A.t', S 6ttitk
City/State/Zip: FCCaeva_1 V'Jck.14 i WA Tie 1e`;
Work Phone No.(Ext): ),S..;- 5-2-4 0 i
Work Email Address: J'wt • l'Cv-vcit(aeCI Oft---CaeYAi Way' C6 WI
Please include a copy of one of the following documents,with your name on the document,with your ESAF to prove your
association with the facility-(ies).
• Your permit's letter of coverage
• Your permit's cover sheet
• A previously submitted DMR
• A correspondence from Ecology that has both the facility name and permit number on the same page(c,1fc..et,.ed)
• Signature authority delegation letter signed by the permittee(responsible official).
4.Electronic Signature Agreement and Certification Statement -
By completing and submitting this form to Ecology, I agree to follow the rules and procedures governing the Electronic Signature
account. I also agree that the reports and documents I submit under my Electronic Signature will be used as the corresponding
paper report would. I want to submit the following report(s)or document(s)using WQWebPortal with an electronic signature.
xDischarge Monitoring Reports/Submittals ❑ Notice of Intent(Permit Applications) ❑ Certificate of No Exposure
. crs3c e L.-;:. ' r r _. .ioi. 4 "?t.a r•.ipz•"�gBa
All submittals to the Department of Ecology under this WQWebPortal application are subject to the following certification,as
required by federal and state regulations:
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. The information
submitted is,to the best of my knowledge and belief, true,accurate, and complete and I am aware that there are significant
penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
,kR- 4" �t:aes ^at9. :j . # ..
I agree that I will: I agree that I will not.
• Protect my Electronic Signature account,which includes • Let anyone else use my Electronic Signature account.
my answers to the verification questions and my
password;
• Review the content and meaning of my submitted
Annual Reports and Notifications;
• Within 24 hours of discovery, report to Ecology if:
o My Electronic Signature account is lost, stolen or used
by someone else;
o There is any difference between the information I
submitted and the information displayed in WebDMR;
o My role as a signer for this organization changes.
Agree: (initial here) Agree: I/ (initial here)
I, t) i rA t V V- \. (print Electronic Signer's name),understand that:
1. My electronic signature is legally the same as my handwritten signature for the purpose of compliance with the relevant
environmental regulations;
2. A failure to timely notify Ecology of a possible misuse of my Electronic Signature account may result in my liability for the
information submitted;
3. There are significant penalties for submitting false information, including possible fines and imprisonment, related to the
federal Department of Justice and federal environmental program;
4. I will be asked to verify that I am following the rules outlined in this agreement when I electronically submit documents.
t -.,--.ta.,�°e I . . .. This form cannot be processed without a handwritten signature.
dr
j3//5
E ct •nic Sig -r's Signature t
�1 � ���V-�\.‘ 1,1\A 01 0 r
Name(print or type) Title
, ,,, ,, q,� ,,,tt){ f ,g,o�.„/, a,,i.t< 7) This form cannot be processed without a handwritten signature.
I, (insert name of permittee or responsible official)acknowledge that the individual named
above works at/for (insert site/facility name)and is authorized to submit
documents on the site's/facility's behalf. I understand that I will be contacted by Ecology to validate the account holder's
employment at the site/facility name listed above.
Signature Date
Name(print or type) Title
Note:You may skip this section if the responsible official has written,signed,and attached a delegation letter to this form or if the responsible
official completes this form.
If you need this document in a version for the visually impaired call the Water Quality Program at 360-407-6401. Persons with
hearing loss, call 711 for Washington Relay Service. Persons with a speech disability, call 877-833-6341.
' a e
;,P,„Net-41410.;lgillg(U}:i4:108)b. This section cannot be processed without a handwritten signature.
I, L vv. v -c,kl (insert name of permittee or responsible official)acknowledge that
n i C S l t tI CAl (person being assigned)is authorized to be an administrator on the site's/facility's
behalf. I understand that I will be contacted by Ecology to validate the account holder's employment at the site/facility name listed
above.
411. lUALLer
;16//lA/15- •
Signatu D e
Vvt 'Pe v-v- k k
Name(print or type) Title
Note:You may skip this section if the responsible official has written,signed,and attached a delegation letter to this form,if the responsible official
completes this form,or if the responsible official is not assigning a person to the administrator role.
Mail the signed electronic signature agreement and additional document(s)to one of the following Ecology office.
Stormwater Permit Facilities—Industrial and Industrial Section
Construction Stormwater
Washington Department of Ecology
Washington Department of Ecology Water Quality Program Major Industrial Unit
Water Quality Program Stormwater Unit P.O. Box 47600
P.O. Box 47696 Olympia,WA 98504-7600
Olympia,WA 98504-7696 360-407-6945
360-407-7097
For all other permits, please contact one of the follow offices.
Clallam, Clark, Cowlitz, Grays Harbor, Jefferson, Mason, Adams, Asotin, Columbia, Ferry, Franklin, Garfield, Grant,
Lewis, Pacific, Pierce, Skamania, Thurston, and Lincoln, Pend Oreille, Spokane, Stevens, Walla Walla, and
Wahkiakum counties Whitman counties
Washington Department of Ecology Washington Department of Ecology
Water Quality Program - SWRO Water Quality Program- ERO
PO Box 47775 N.4601 Monroe
Olympia,WA 98504-7775 Spokane,WA 99205-1295
360-407-6300 509-329-3400
Benton, Chelan, Douglas, Kittitas, Klickitat, Okanogan, Island, King, Kitsap, San Juan, Skagit, Snohomish, and
and Yakima counties Whatcom counties
Washington Department of Ecology Washington Department of Ecology
Water Quality Program - CRO Water Quality Program- NWRO
15 West Yakima Ave--Suite 200 ATTN: Chris Smith
Yakima,WA 98902-3452 3190- 160th Ave. SE
509-575-2490 Bellevue,WA 98008-5452
425-649-7000