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AG 15-060 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 EXECUTE" "ORIGINALS t2ECTI20A//L ACLOLIM /94I P ,S'ErVP 7771/S 4C00uvr 1440 ALLDW 7-NE /I19ya2 7b SW•I/ ,— ` ,VP12 s' 44A1U'L Pc-11M/T: /.9!rr- Sr6P SECac 77E 196661141T /f ,4f2J'E ,s 7n S.-SA) )E #17rAcia, P F/r 44'D n4ArL. 74c4 ra £eacoGy, 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